Central line insertion in deranged clotting
Date First Published:
December 21, 2010
Last Updated:
June 7, 2011
Report by:
Janos Peter Baombe , Senior Emergency Trainee (Manchester Royal Infirmary )
Search checked by:
Laith Sultan , Manchester Royal Infirmary
Three-Part Question:
In [adult patients presenting to the ED with deranged/unknown clotting profile], does [the insertion of a central line under ultrasound guidance] reduce [the risk of significant bleeding]?
Clinical Scenario:
A 65-year-old man is brought to the Emergency Department with no recordable blood pressure and a temperature of 39°C. You attempt unsuccessfully to insert a peripheral line several times and you decide to cannulate a central vein. Your colleague asks you if it would not be wiser to wait for the patient’s blood coagulation profile to avoid potential bleeding complication.
Search Strategy:
Medline using the OVID interface 1950 to November week 2 2010
EMBASE 1980 to December week 2 2010
EMBASE 1980 to December week 2 2010
Search Details:
Medline: [(exp Catheterization, Central Venous/) OR (central line.mp) OR (exp Catheters, Indwelling/) OR (exp Catheterization/) OR (central lin$.mp) OR(CVC.mp)] AND [(exp Blood Coagulation Disorders/) OR (coagulopathy.mp) OR (exp Thrombocytopenia/) OR (coagulopath$.mp) OR (exp international normalized ratio/) OR (INR.mp) OR (deranged clotting.mp) OR (abnormal clotting.mp)]
Limit search to English language, humans and all adult. 413 papers were found, 4 were relevant to the question
Embase:{[exp central venous catheter/ OR exp central venous catheterization/] AND [(exp blood clotting disorder/) OR (exp international normalized ratio/) OR (exp blood clotting/) OR (thrombocytopenia/)]} AND {[complication/]}. Limit to humans, adults and English language. 257 papers were found, one relevant to the question that was a duplicate from the search above.
Limit search to English language, humans and all adult. 413 papers were found, 4 were relevant to the question
Embase:{[exp central venous catheter/ OR exp central venous catheterization/] AND [(exp blood clotting disorder/) OR (exp international normalized ratio/) OR (exp blood clotting/) OR (thrombocytopenia/)]} AND {[complication/]}. Limit to humans, adults and English language. 257 papers were found, one relevant to the question that was a duplicate from the search above.
Outcome:
4 relevant papers
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Uncomplicated central vein catheterization of high risk patients with real time ultrasound guidance. Gallieni M, Cozzolino M. 1995, Italy | 10 patients had CVC inserted with the landmark technique, 31 patients had US-guided CVC insertion (12 high risk with coagulopathy). | Prospective observational study | Number of attempts. | 13 cannulations in high risk patients successful at first attempt. | Single inexperienced operator. Small numbers. |
| Success rate. | 100% success rate. | ||||
| Complications. | No complications, except for 3 arterial punctures in landmark group and one in US group. | ||||
| Coagulation disorders in patients with cancer: nontunneled central venous catheter placement with US guidance--a single-institution retrospective analysis. Della Vigna P, Monfardini L, Bonomo G et al. 2008, Italy | 157 patients with a disorder of haemostasis had 239 CV line insertions. Increased risk was defined as: PT/APTT 1.2x normal and/or plts<150.109/L High risk was defined as: PT/APTT>2.2x normal, and/or plts<50.109/L |
Retrospective study | Number of passes. | 122 CVCs inserted in haemostatic disorders (45 in high risk patients, 77 in increased risk patients). | A retrospective study performed by experienced radiologists. Oncology patients |
| Number and extent of complications. | No arterial puncture, no complications, no correction of coagulation parameters recorded. | ||||
| Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters. Weigand K, Encke J, Meyer FJ, et al. 2009, Germany | 196 patients, 65 with disorders of haemostasis (PT≤50% or INR ≥1.5, platelets ≤50.109/L) had US-guided CVC insertion. Patients who had received FFP/RBC/plts within 24 hours were excluded. |
Prospective study | Complication defined as > Hb 1.5g/dl drop 24-36 hours post-procedure. Compared mean platelet count between the group with Hb drop and those with no drop were similar for INR, PT. | No statistical difference for platelets, PT or INR groups (p=0.024, 0.164 and 0.363 respectively). A subgroup analysis of combined derangements showed no statistical difference either. | Number of patients with extreme values was too low to detect statistical significance. |
| US-guided placement of central vein catheters in patients with disorders of hemostasis. Tercan F, Ozkan U, Oguzkurt L. 2008, Turkey | 133 US-guided CVC insertions in 119 patients with disorders of haemostasis (platelets ≤50.109/L, INR ≥1.5, APTT ≥50 alone or combined) |
Prospective study | Number of attempts, | Average number of punctures 1.01 (range 1-2). | Study performed by interventional radiologists. 5 patients were lost to follow-up. |
| Success rate. | Success rate 100% (1st puncture 98.5% and 2nd 1.5%). | ||||
| Recorded single or double-wall puncture. | Single-wall puncture 89.5%, double-wall puncture 10.5%. | ||||
| complications within 24 hours, | Minor complication rate 6% (oozing, haematoma). An association was found between high INR and haematoma rate (p<0.05). Platelet count, APTT, number of punctures, and diameter of line were not associated with haematoma (p>0.05). |
Author Commentary:
Adequate vascular access is often of paramount importance in the Emergency Department. CVC insertion is potentially accompanied by complications such as pneumothorax, air embolism, mediastinal haematoma, haemothorax, tracheal injury or local bleeding (McGee). Ultrasound-guided placement of CVC has been shown to decrease failures, procedural time and complications by large-scale studies (Hind). The guidance issue by the National Institute for Clinical Excellence (NICE) recommends the use of ultrasonography for the insertion of central lines.<br><br>Invasive lines are frequently inserted in patients as an emergency procedure and this often with unknown or deranged coagulation profiles. The above studies seem to suggest that insertion of CVC lines do not require correction of haemostatic abnormalities prior to intervention. Rates of haemorrhage are low in patients with elevated PT, APTT or low thrombocyte count and appear to be closely related to the level of experience of the physician (Bernard) rather than the defects of haemostasis.
Bottom Line:
Ultrasound-guided central line insertion in patients with coagulopathy is safe if performed by an experienced operator.
References:
- McGee, Gould MK. . Preventing complications of central venous catheterization.
- Hind D, Calvert N, McWilliams R., et al. . Ultrasonic locating devices for central venous cannulation meta-analysis.
- National Institute for Clinical Effectiveness.. TA49 Central venous catheters - ultrasound locating devices: guidance
- Bernard RW, Stahl WM. . Subclavian vein catheterization: a prospective study. I. Non-infectious complications.
- Gallieni M, Cozzolino M.. Uncomplicated central vein catheterization of high risk patients with real time ultrasound guidance.
- Della Vigna P, Monfardini L, Bonomo G et al.. Coagulation disorders in patients with cancer: nontunneled central venous catheter placement with US guidance--a single-institution retrospective analysis.
- Weigand K, Encke J, Meyer FJ, et al.. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters.
- Tercan F, Ozkan U, Oguzkurt L.. US-guided placement of central vein catheters in patients with disorders of hemostasis.