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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

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.

Search Outcome

4 relevant papers

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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.
Della Vigna 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.
Weigand 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.
Tercan et al, 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).

Comment(s)

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.

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.

Clinical Bottom Line

Ultrasound-guided central line insertion in patients with coagulopathy is safe if performed by an experienced operator.

References

1. McGee, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-1133.
2. Hind D, Calvert N, McWilliams R., et al. Ultrasonic locating devices for central venous cannulation meta-analysis. BMJ 2003;327:361-368.
3. National Institute for Clinical Effectiveness. TA49 Central venous catheters - ultrasound locating devices: guidance NICE http://guidance.nice.org.uk/TA49/Guidance/pdf/English. Accessed 11/12/2010
4. Bernard RW, Stahl WM. Subclavian vein catheterization: a prospective study. I. Non-infectious complications. Ann Surg 1971;173:184-190
5. Gallieni M, Cozzolino M. Uncomplicated central vein catheterization of high risk patients with real time ultrasound guidance. Int J Artif Organs. 1995 Mar;18(3):117-21.
6. 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. Radiology. 2009 Oct;253(1):249-52. Epub 2009 Jun 30.
7. 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. Med Klin (Munich). 2009 May 15;104(5):331-5. Epub 2009 May 16.
8. Tercan F, Ozkan U, Oguzkurt L. US-guided placement of central vein catheters in patients with disorders of hemostasis. Eur J Radiol . 2008 Feb;65(2):253-6. Epub 2007 May 4.