Abstract
Objectives
Central venous catheterization (CVC) is thought to be relatively contraindicated in
patients with thrombocytopenia or coagulopathy. We measured the 24-hour incidence
of bleeding in septic emergency department (ED) patients undergoing CVC.
Methods
This multicenter, retrospective cohort study included septic ED patients undergoing
CVC with one of the following: platelets less than 100 000/μL, international normalized ratio at least 1.3, or partial thromboplastin time at
least 35 seconds. Major bleeding included radiographically confirmed intrathoracic,
mediastinal, or internal neck hemorrhage or line-related bleeding causing hemodynamic
compromise. Minor bleeding included local oozing or superficial hematoma. Multivariable
regression analysis was performed to determine the association between candidate variables
and hemorrhagic complications.
Results
Of the 936 cases, mean age was 68.1 years; 535 (57.2%) were male. Two or more qualifying
laboratory abnormalities were present in 204 cases (21.8%). The proceduralists were
predominately attendings (790; 84.4%). The initial veins were the internal jugular
(n = 800; 85.5%), subclavian (n = 123; 13.1%), and femoral (n = 13; 1.4%). Initial
access was successful in 872 cases (93.2%). We found one case (95% upper confidence
limit: 0.6%) of major bleeding and 37 cases (4.0%; 95% confidence interval [CI], 2.8%-5.4%)
of minor bleeding. Only failed access at the initial site was independently associated
with hemorrhagic outcomes: adjusted odds ratio 8.2 (95% CI, 3.7-18.0).
Conclusions
Major bleeding from CVC in ED patients with abnormal hemostasis is rare. Minor bleeding
is uncommon and infrequently requires intervention. Successful catheterization on
the initial attempt is associated with fewer hemorrhagic complications. These results
can inform the risk/benefit calculus for CVC in this population.
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References
- Increased rate of central venous catheterization procedures in community EDs.Am J Emerg Med. 2010; 28: 208-212
- Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study.Crit Care Med. 2013; 41: 1450-1457
- Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.Crit Care Med. 2013; 41: 580-637
- Reducing mortality in severe sepsis and septic shock.Semin Respir Crit Care Med. 2011; 32: 195-205
- Clinical procedures in emergency medicine.6th ed. Saunders, Philadelphia, PA2013
- Central venous catheterization.Crit Care Med. 2007; 35: 1390-1396
- Predictors of unattempted central venous catheterization in septic patients eligible for early goal-directed therapy.West J Emerg Med. 2014; 15: 67-75
- Emergency physician perspectives on central venous catheterization in septic patients: a survey-based study.Acad Emerg Med. 2014; ([in press])
- Ultrasonography-guided central venous catheterisation in haematological patients with severe thrombocytopenia.Blood Transfus. 2013; : 1-5
- Central line placement in patients with and without prophylactic plasma.J Crit Care. 2012; 27: 529 e9-e13
- Factors associated with prophylactic plasma transfusion before vascular catheterization in non-bleeding critically ill adults with prolonged prothrombin time: a case-control study.Br J Anaesth. 2012; 109: 919-927
- Large-bore tunneled central venous catheter insertion in patients with coagulopathy.J Vasc Interv Radiol. 2010; 21: 212-217
- Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: a prospective observational study of 1,978 consecutive catheterizations.World J Surg Oncol. 2010; 8: 91
- Coagulation disorders in patients with cancer: nontunneled central venous catheter placement with US guidance—a single-institution retrospective analysis.Radiology. 2009; 253: 249-252
- 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; 104: 331-335
- US-guided placement of temporary internal jugular vein catheters: immediate technical success and complications in normal and high-risk patients.Eur J Radiol. 2005; 55: 125-129
- US-guided placement of central vein catheters in patients with disorders of hemostasis.Eur J Radiol. 2008; 65: 253-256
- Central venous catheter placement in patients with disorders of hemostasis.Am J Surg. 2000; 180 (discussion 6): 503-505
- Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit.Intensive Care Med. 1999; 25: 481-485
- Invasive line placement in critically ill patients: do hemostatic defects matter?.Transfusion. 1996; 36: 827-831
- Central venous catheter placement in patients with disorders of hemostasis.Chest. 1996; 110: 185-188
- Central venous catheterization in patients with coagulopathy.Arch Surg. 1992; 127: 273-275
- Percutaneous cannulation of the internal jugular vein in patients with coagulopathies: an experience based on 1,000 attempts.Anesthesiology. 1982; 56: 321-323
- Kaiser Permanente’s performance improvement system, part 3: multisite improvements in care for patients with sepsis.Jt Comm J Qual Patient Saf. 2011; 37: 483-493
- An integrated EHR at Northern California Kaiser Permanente: pitfalls, challenges, and benefits experienced in transitioning.Appl Clin Inf. 2012; 3: 318-325
- Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients.Intensive Care Med. 2002; 28: 1036-1041
- Complications and failures of subclavian-vein catheterization.N Engl J Med. 1994; 331: 1735-1738
- Central vein catheterization. Failure and complication rates by three percutaneous approaches.Arch Intern Med. 1986; 146: 259-261
- What is the best site for central venous catheter insertion in critically ill patients?.Crit Care. 2003; 7: 397-399
- Best evidence topic report. Central venous catheterisation: internal jugular or subclavian approach?.Emerg Med J. 2007; 24: 662-663
- Mechanical complications of central venous catheters.J Intensive Care Med. 2006; 21: 40-46
- Preventing complications of central venous catheterization.N Engl J Med. 2003; 348: 1123-1133
- Limiting vein puncture to three needle passes in subclavian vein catheterization by the infraclavicular approach.Surg Today. 2006; 36: 779-782
- Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis.Anesthesiology. 2013; 118: 361-375
- International evidence-based recommendations on ultrasound-guided vascular access.Intensive Care Med. 2012; 38: 1105-1117
- Ultrasonic locating devices for central venous cannulation: meta-analysis.BMJ. 2003; 327: 361
- Internal jugular vein cannulation: an ultrasound-guided technique versus a landmark-guided technique.Clinics (Sao Paulo). 2009; 64: 989-992
- Impact of ultrasonography on central venous catheter insertion in intensive care.Indian J Radiol Imaging. 2009; 19: 191-198
- Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients.Crit Care. 2006; 10: R162
- Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study.Ann Emerg Med. 2006; 48: 540-547
- Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) trial.Crit Care Med. 2005; 33: 1764-1769
- Risk factors for acute adverse events during ultrasound-guided central venous cannulation in the emergency department.Acad Emerg Med. 2010; 17: 1055-1061
- Factors influencing physicians’ reported use of anticoagulation therapy in nonvalvular atrial fibrillation: a cross-sectional survey.Clin Ther. 2003; 25: 1750-1764
Article Info
Publication History
Published online: March 20, 2014
Accepted:
March 4,
2014
Received in revised form:
March 3,
2014
Received:
January 26,
2014
Footnotes
☆Sources of Support: The study was supported by a grant from the Gordon and Betty Moore Foundation, Palo Alto, CA.
☆☆Presentation: This study was presented in part at the Research Forum, American College of Emergency Physicians Scientific Assembly, Seattle, WA, October 2013.
★Author Contributions: All authors contributed to the study conception and design as well as procurement of funding. ASR provided administrative support. LGH, DRV, DGM, DWB, and YYH collected the data. YYH analyzed and DRV, DWB, and DGM interpreted the data. DRV drafted the manuscript, and all authors contributed substantively to its critical revision and its final approval. DRV takes responsibility for the manuscript as a whole.
Identification
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© 2014 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
