#60 Journal Club: Save the RIJ?
This week on Critical Care Time, Nick & Cyrus discuss the recent article in the Journal of Critical Care titled “Impact of initial jugular vein insertion site selection for central venous catheter placement on hemodialysis catheter complications.” Is this bunk or is this practice changing? Did they select the right population for this study or is the question they asked and answered... maybe not such a great question? We'll cover all this and more during this week's episode! Please take a listen, react, reach out & as always - don't forget to leave a review!
Should we save the RIJ?
Should intensivists routinely place central lines in the right internal jugular or “save” that special site for potential future lines? Some intensivists and institutions strongly believe that the right internal jugular vein should be preserved in case a patient requires a hemodialysis line in the future. The "Save the RIJ" dogma is based on the premise that it is technically more difficult to place hemodialysis lines in the LIJ (or femoral) vein. Proponents argue that by preserving the RIJ, the "cumulative procedural risk" can be lowered.
Others disagree. If this assumption is true, by prioritizing the LIJ, we are exposing every patient who needs venous access to a higher rate of complications, in the hope of reducing the rate of complications for the subset who might need one of these lines later.
This is controversial.
We built this interactive web calculator to help clinicians decide for themselves based on thier own assumptions about LEFT vs RIGHT IJ complications as well as institutional rates of CRRT which strategy has the lower cumulative risk to their patients. By expressing the total risk per 100 patients, hopefully we can make informed decisions that mitigate harm:
Should I "Save the RIJ" for a Potential Future HD Line?
| LEFT IJ | RIGHT IJ | |
|---|---|---|
| CVC complication rate (%) | ||
| HD line complication rate (%) |
Source code available here (open source as always)
Our view: Use the RIJ, don’t save it!
Nick: My view is that we should do the lowest risk procedure (aka a RIJ central line) in every patient who needs it. Systematically “saving” the RIJ exposes everyone to higher procedural risk for a theoretical benefit in a minority of patients. If you do the math, as I have, you are exposing far more people to harm by “preserving the RIJ".”
What do you think?
Sponsors
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Gharaibeh et al, Impact of Initial Jugular Vein Insertion Site Selection for Central Venous Catheter Placement on Hemodialysis Catheter Complications, Journal of Critical Care 2025
Parienta et al, Intravascular Complications of Central Venous Catheterization by Insertion Site, NEJM 2015
Sulek et al, A randomized study of left versus right internal jugular vein cannulation in adults, Journal of Clinical Anesthesia 2000
Oliveros et al, Effect of renal support therapy on 5-year survival in patients discharged from the intensive care unit, Journal of Intensive Care 2020