Central venous catheter placement in coagulopathic patients: risk factors and incidence of bleeding complications

Abstract

BACKGROUND Central venous catheters are frequently inserted into patients with coagulation disorders. It is unclear whether preprocedural correction of hemostasis is beneficial. We determined the incidence of bleeding complications after central venous catheter placement in patients who had severe coagulopathy and identified potential risk factors for bleeding. STUDY DESIGN AND METHODS The MEDLINE and Cochrane Library databases were systematically searched through November 2015. To be included, articles must have reported on hemorrhagic complications with specification of abnormal coagulation testing results. Severe coagulopathy was defined as a reduced platelet count of 50 × 109/L or less, and/or an elevated international normalized ratio of 1.5 or greater, and/or a partial thromboplastin time of 45 seconds or greater. RESULTS We included one randomized controlled trial and 21 observational studies. In total, there were 13,256 catheter insertions, including 4213 in patients with severe coagulopathy. Before 3150 central venous catheter placements, coagulopathy was not corrected. The bleeding incidence varied from 0 to 32%. The severity of coagulopathy did not predict the risk of bleeding. No study demonstrated a beneficial effect from the prophylactic administration of platelets or fresh‐frozen plasma to prevent bleeding complications. Retrospective observational studies suggested that no preprocedural correction is required up to a platelet count of 20 × 109/L and an international normalized ratio of 3.0. CONCLUSION The incidence of major bleeding complications after central venous catheter placement is low, even in coagulopathic patients. Based on a systematic research of the literature, strong evidence supporting the correction of hemostatic defects before central venous catheter insertion is lacking. However, well‐powered randomized controlled trials will be necessary to determine the minimal platelet count, the maximal international normalized ratio, and an activated partial thromboplastin time that is safe before central venous catheter insertion.

Bleeding assessment and bleeding severity in thrombocytopenic patients undergoing invasive procedures

“…This is in line with earlier results concerning both SAE reporting and clinical bleeding. 1,7,30 Also, we have shown that the way of reporting bleeding assessment is often limited. The lack of this essential information reduces the validity and hampers the reproducibility of these studies.…”

“…P atients with a low platelet count (thrombocytopenia) have an increased risk of both spontaneous and post-procedural bleeding. 1,2 Platelet transfusions are therefore recommended in various guidelines, [3][4][5] either when the platelet count drops below a certain threshold or prior to invasive procedures. The clinical studies forming the basis of these guidelines are known to be of low quality, [3][4][5][6] essentially reducing the value of transfusion guidelines to the quality level of expert opinion.…”

“…A recent review on coagulopathy prior to central venous catheter (CVC) placement by our group, also found a large variance in the incidence of bleeding. 1 Several bleeding scales have been developed to help clinicians and researchers assess bleeding. The most widely used of these is the World Health Organization (WHO) bleeding scale, 8 which was created to standardize toxicity reporting in cancer treatment.…”

Vascular access for red blood cell exchange

“…63,71,75 Major bleeding from CVC insertion is uncommon, even in patients who have thrombocytopenia and coagulation disorders. 76 Catheter placement can be performed safely with platelet counts of 20 3 10 9 /L or greater. 77 This complication is less likely to be a problem in patients with SCD, who usually have normal or increased platelet counts.…”

Clinical bleeding and thrombin generation in admissions to critical care with prolonged prothrombin time: an exploratory study

“…For example, a recent systematic review was unable to identify values of coagulation tests, including the prothrombin time (PT) or international normalized ratio, required to support safe central venous catheterization. 1 It is also well recognized that the PT and activated partial thromboplastin time provide only a very limited assessment of hemostatic status, for several reasons: these include that the PT and activated partial thromboplastin time measure the time taken for a clot to form which occurs when only 5% of total thrombin generation (TG) has occurred, they reflect only the procoagulant factors and are unaffected by the levels of natural anticoagulants, they are insensitive to modest but clinically relevant low levels of procoagulant factors, and finally they are poor at identifying a prothrombotic state. [2][3][4][5] Despite being some of the most frequently ordered hematology investigations in hospital practice, conventional coagulation tests may therefore have limited predictive value for clinical bleeding and the safety of invasive procedures, 6 and their role in indicating a need for plasma transfusion in nonbleeding patients remains unclear.…”