Abstract
BACKGROUND: Classic teaching in neurocritical care is to avoid jugular access for central venous catheterization (CVC) because of a presumed risk of increasing intracranial pressure (ICP). Limited data exist to test this hypothesis. Aneurysmal subarachnoid hemorrhage (aSAH) leads to diffuse cerebral edema and often requires external ventricular drains (EVDs), which provide direct ICP measurements. Here, we test whether CVC access site correlates with ICP measurements and catheter-associated complications in patients with aSAH. METHODS: In a single-center retrospective cohort study, patients with aSAH admitted to Emory University Hospital between January 1, 2012, through December 31, 2020, were included. Patients were assigned by the access site of the first CVC placed. The subset of patients with an EVD were further studied. ICP measurements were analyzed using linear mixed effect models, with a binary comparison between internal-jugular (IJ) versus non-IJ access. RESULTS: A total of 1577 patients were admitted during the study period with CVC access: subclavian (SC) (887, 56.2%), IJ (365, 23.1%), femoral (72, 4.6%), and peripheral inserted central catheter (PICC) (253, 16.0%). Traumatic pneumothorax was the most common with SC access (3.0%, p < 0.01). Catheter-associated infections did not differ between sites. Catheter-associated deep venous thrombosis was most common in femoral (8.3%) and PICC (3.6%) access (p < 0.05). A total of 1220 patients had an EVD, remained open by default, generating 351,462 ICP measurements. ICP measurements, as compared over the first 24-postinsertion hours and the next 10 days, were similar between the two groups. Subgroup analysis accounting for World Federation of Neurological Surgeons grade on presentation yielded similar results. CONCLUSIONS: Contrary to classic teaching, we find that IJ CVC placement was not associated with increased ICP in the clinical context of the largest, quantitative data set to date. Further, IJ access was the least likely to be associated with an access-site complication when compared with SC, femoral, and PICC. Together, these data support the safety, and perhaps preference, of ultrasound-guided IJ venous catheterization in neurocritically ill patients.