Placing Central Lines in Thrombocytopenic Patients
Placing Central Lines in Thrombocytopenic Patients
Abstract & Commentary
Synopsis: Central venous catheters can be safely placed in cancer patients with platelet counts of less than 20,000/mm3.
Source: Berrara R, et al. Cancer 1996;78:2025-2030.
Thrombocytopenia frequently complicates cancer therapy. Patients with very low platelet counts are at risk for increased bleeding complications, especially if the count is less than 10,000-20,000/mm3. Since these patients also frequently require placement of central venous catheters for administration of fluid and medication, for parenteral alimentation, and for hemodynamic monitoring, there is obvious concern for safety.
Berrera et al at the Memorial Sloan-Kettering Cancer Center performed a prospective evaluation of the acute complications associated with percutaneous placement of central lines in cancer patients with platelet counts less than 20,000/mm3. All lines were placed by members of the Critical Care Medicine service. Either triple-lumen catheters (7 French) or Introducer Sheaths (8 French) were placed, using the Seldinger technique. Either the internal jugular or subclavian vein site was chosen at the discretion of the operator. Platelet transfusions were given in an attempt to raise the platelet count above 20,000/mm3. The number of placement attempts was recorded, the site was inspected immediately, and also on the following day, a chest radiograph was obtained following the procedure to evaluate for complications.
A total of 115 catheters were placed (subclavian, 63 [right, 52; left, 11]; internal jugular, 52 [right, 40; left, 12]). The patients’ mean age was 49 ± 16 years (range, 18-100). The mean platelet count was 14,600 ± 4700/mm3 before transfusion and 24,300 ± 13,800/mm3 after transfusion. Four patients received fresh frozen plasma due to concomitant presence of prolonged prothrombin and partial thromboplastin times. In all, there were 24 complications (21%). Only one of these was a major complicationa pnuemothorax following an internal jugular line placement. Minor complications included blood oozing and small hematomas. These occured in seven subclavian lines and 16 internal jugular lines. There were no differences in platelet counts between those patients with and without complications. However, complications were associated with a higher number of attempts at placement (1.2 ± 0.5 vs 1.6 ± 1.0; P = 0.003). The adjusted odds ratio for complications at the internal jugular compared to the subclavian site was 5.5 (95%, CI 1.8, 15.7).
COMMENT BY STEPHEN W. CRAWFORD, MD
Placing large needles into the necks or chests of patients with very low platelet counts gives most of us more than a moment of pause. Many intensivists have developed bias as to which approach is safest and what platelet count is adequate. The authors of this study present us with data suggesting that with platelet transfusion to acheive a platelet count exceeding 20,000/mm3, central lines can be placed with minimal complication. Even though they report a 21% complication rate, the majority of these complications were minor and in my view, acceptable in this population of patients.
The higher rate of oozing and hematoma seen at the internal jugular site was likely related to the superficial location and greater ease of visualization. I cannot make a lot out the increased rate of these complications compared to the subclavian approach. The increased rate of complications seen with more attempts at line placement has been noted by other investigators. In this study, increased age and type of cancer were not associated with a risk of complication.
Although not included in the report of complications, the authors note that there were five lines that could not be placed. All five of these occurrences were attempts at the jugular site. All subclavian site attempts were successful. I would have prefered to have had these attempts included as complications. If included, the complication rate for the internal jugular approach would have been 39%, with 11% related to pneumothorax or failed line placement. It is true that these failures were probably not related to the thrombocytopenia; however, I find the comparison of the internal jugular to subclavian vein approach interesting. I would not have expected the subclavian site to be safer. Whether this apparent advantage of the subclavian vein over the internal jugular vein is generalizable to our practices, or is related to the skills of the staff at Memorial Sloan-Kettering, is unclear. I personally feel more comfortable with the internal jugular approach. However, on the basis of this study, I can no longer say it is safer in my thrombocytopenic patients.
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