- Email: [email protected]
Point: Should Coagulopathy Be Repaired Prior to Central Venous Line Insertion? Yes
CHEST Point: Should Coagulopathy Be Repaired Prior to Central Venous Line Insertion? Yes Why Take Chances? Abbreviations: CVC 5 central venous catheter; IJ 5 internal jugular; INR 5 international normalized ratio; PTT 5 partial thromboplastin time; TRALI 5 transfusion-associated lung injury; US-CVC 5 ultrasound-guided central venous catheter insertion
the number of studies in the literature Although that address the question of coagulopathy rever-
sal prior to central venous catheter (CVC) insertion is small, and the question has been a difficult one to address with large trials, the issue is an extremely important one. Rather than operating based on experiential data and “gut feelings” (as we often do), a review of the existing literature in the context of my personal experience practicing in an ICU that cares for many patients with coagulopathy leads me to conclude that reversal of coagulopathy should be pursued prior to central line insertion (when feasible to do so). Given the increasing availability of peripherally inserted central catheters for more stable patients, the insertion of traditional central venous lines is increasingly used more exclusively in critically ill patients for monitoring and support in the ICU. Thus, the risk of any mechanical complication is heightened in critically ill patients with coagulopathy who have little reserve to tolerate additional hemodynamic derangements. I will first review the small pool of existing recent literature describing the risks of mechanical complications following central line insertion with ultrasound guidance; then, for comparison, I will briefly review the risks of life-threatening complications for patients after receipt of blood products for reversal of coagulopathy. Finally, I will conclude that the data support my experience and gut feelings that the riskto-benefit ratio for our critically ill patients favors reversing a coagulopathy prior to central line insertion. Risks of Central Line Insertion To frame the argument in favor of correction of coagulopathy prior to central line insertion, one must www.chestpubs.org
Point/Counterpoint Editorials
first assess the risks of CVC insertion and, in particular, the risk of mechanical complications that include arterial puncture, bleeding, and hematoma formation. Notably, mechanical complications occur in 5% to 19% of line insertions and vary with the site chosen for line insertion, with many reports suggesting that the femoral vein site has the highest overall rates of mechanical complication (especially arterial puncture and hematoma), followed by the subclavian vein site (especially pneumothorax and hemorrhage requiring transfusion), followed by the internal jugular (IJ) vein site as the lowest-risk site, with arterial puncture as the most frequent mechanical complication.1 Importantly, the risk of mechanical complications with CVC insertion has declined in recent years with the introduction of ultrasound-guided CVC insertion (US-CVC), and a number of professional societies have recommended US-CVC preferentially using the IJ location for both the relative safety of insertion at this site and the amenability of this site for ultrasound guidance.2-4 Thus, I will focus the rest of the debate in the context of US-CVC at the IJ site (even though this gives my opponent a substantial advantage, as this approach is now believed to be the safest overall approach in terms of minimizing mechanical complications). Even with use of US-CVC, studies still report significant mechanical complications, including bleeding, with a study from an academic medical center5 reporting a mechanical complication rate of close to 20% (Table 1).5-8 Although studies have identified different risk factors for bleeding with CVC, including severe coagulopathy, end-stage renal disease, very high or low BMI, dehydration, and number of needle passes required for successful cannulation, many studies identified inexperience of the operator as a critical risk factor for the development of mechanical complications. Interestingly, one recent study called into question the definition of an experienced operator, in that the highest risk of complications was observed in operators with intermediate levels of experience, whereas novice and senior operators exhibited less risk of complications.5 The authors speculate that novice operators were under the supervision of more senior operators, whereas intermediate operators might have been on their own and less experienced as the sole CHEST / 141 / 5 / MAY, 2012
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
1139
Table 1—Review of Literature Addressing US-CVC in Patients With Coagulopathy Study/Year, Location
Coagulopathic Insertions, No.
Study Design
Della Vigna et al /2009, 122 insertions (45 of these Italy deemed at high risk of bleeding); coagulopathy not corrected 6
Weigand et al7/2009, Germany
Tercan et al3/2008, Turkey
Theodoro et al5/2010, United States
Outcomes, Findings
Retrospective; interventional All CVCs placed on first radiology operators; pass; no bleeding; only subjects with cancer 3% of CVCs placed in IJ site (remainder in SCV site) 65 insertions (seven of these Prospective; operators No difference in significant with high risk of bleeding); with range of experience, bleeding in subjects with coagulopathy not corrected; including house officers; vs subjects without LMWH not administered heterogeneous patient coagulopathy; 88% of within 6 h of CVC insertion population CVCs placed in IJ site (2% SCV, 10% femoral) 133 insertions (80.5% with Prospective; experienced Association observed one coagulopathic parameter interventional radiology between elevated INR [ie, of plt, INR, or PTT operators; no correction ( . 1.5) and hematoma values]; 18% with two, and of coagulopathy development; 97% 1.5% with three parameters) undertaken prior of CVCs placed in IJ to CVC (1.5% SCV, 1.5% femoral) Prospective observational; Mechanical complications 43 insertions with INR ⱖ 2 operators with range of significantly higher in (15% of total insertions); experience, including subjects with ESRD and 33 insertions with ESRD house officers who for less-experienced (11% of total insertions) inserted ultrasound-guided operators; 19.7% overall IJ CVCs rate of mechanical complications (including 20 [6.9%] hematomas and 6 [2%] arterial punctures)
Comments No bleeding complications reported retrospectively with experienced operators inserting nontunneled lines Coagulopathy was not predictive of bleeding risk in the very small number of subjects who were coagulopathic INR elevation associated with bleeding risk, whereas platelet level, PTT, other factors were not in this study Difficult to discern overall number of subjects with coagulopathy; not known if subjects with ESRD were coagulopathic; supervision of less-experienced operators is important
CVC 5 central venous catheter; ESRD 5 end-stage renal disease; IJ 5 internal jugular; INR 5 international normalized ratio; LMWH 5 lowmolecular-weight heparin; plt 5 platelet; PTT 5 partial thromboplastin time; SCV 5 subclavian vein; US-CVC 5 ultrasound-guided central venous catheter insertion. (Adapted from Baombe et al.8)
or supervising proceduralists. Notably, this study was conducted in an academic ED and, thus, included analysis of US-CVCs from attending physicians as well as house officers with varying degrees of experience. Interestingly, even with experienced operators and the use of ultrasound, some studies have suggested that mechanical complications may be associated with severe thrombocytopenia (eg, platelet counts , 25,00050,000/mL) or an international normalized ratio (INR) ⱖ 1.5, or with multiple simultaneous coagulopathic derangements (eg, combinations of thrombocytopenia and factor deficiencies with INR ⱖ 1.5 and/or partial thromboplastin time [PTT] . 50 s).3,9 Some authors have argued that even if an arterial puncture is not a frequent event with IJ line insertion (reported as 6% in some studies), there exists the potential for significant risk of these punctures regardless of catheter size. Hematomas are reported to develop following as many as 40% of carotid punctures and can produce life-threatening bleeding if rapid expansion occurs, causing airway compromise. Additionally, carotid punctures pose the risk of development of a life-threatening cerebrovascular event from the need to compress the bleeding site adjacent to the carotid artery (especially in elderly patients with underlying vascular disease).9 Two studies that did not report an increase in bleeding risk with 1140
US-CVC were either retrospective studies6 or included only a small number of patients with coagulopathy,7 making definitive conclusions difficult (Table 1). Risks of Blood Product Infusion for Reversal of Coagulopathy In general, there has been a growing reluctance to transfuse blood products, unless absolutely indicated, especially within the ICU population, given increasing appreciation of possible immune-mediated events in addition to other traditional risks of blood product transfusion.10 However, the blood supply has never been safer in terms of risk of blood productacquired infections, and we must assess the relative risk of a blood product infusion vs the real risk of a mechanical complication related to US-CVC as described previously. Life-threatening risks from blood product administration are generally quite infrequent and can be divided into infectious and noninfectious risks (Table 2). Risks of HIV and hepatitis C are on the order of 1:2 million units transfused or less.11,12 Human error in administering a mismatched product occurs in 1:6,000 to 1:20,000 units, with massive hemolysis as a result of mismatch at a rate of 1:100,000 units.13 Transfusion-associated lung injury Point/Counterpoint Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
Table 2—Examples of Life-Threatening Risks of Blood Product Transfusion Approximate Incidence of Risk Occurrence
Risk of Transfusion Infectious risks: agent HIV Hepatitis C Bacterial infection (contaminated unit) West Nile virus (seasonal) Hepatitis B Noninfectious risks: event Acute hemolysis Anaphylaxis Human error causing mismatch Transfusion-associated lung injury
Approximate incidence per unit 1:2.4 million 1:2 million 1:1 million produces fatality from sepsis 1:350,000 1:200,000 Approximate incidence 1:50,000-1:100,000 1:30,000 1:6,000-1:20,000 1:2,000-1:4,000
(TRALI) is defined as new onset of acute lung injury within 6 h of transfusion not explained by an alternate cause and arises from donor antibodies reacting against the recipient endothelium, producing vascular leak. The risk of TRALI ranges from 1:2,000 to 1:4,000 units (which may be an underestimate due to underreporting), and though TRALI most often subsides spontaneously, it can produce serious consequences.14 Although risks of nonanaphylactic allergic transfusion reactions and volume overload are fairly common as a result of blood product transfusion, these are rarely life threatening. Summary/Conclusions CVC insertion, even with the use of ultrasound at the IJ site, carries a significant risk of mechanical complications. Although the absolute rate of complications is not easily discernible given the small number of studies in the literature and multiple complex factors that contribute to these risks, it is fairly well agreed upon that the employment of experienced operators leads to fewer mechanical complications. However, even in an optimal setting with a low rate of mechanical complications, a serious IJ site bleed can be life threatening given its location near the airway and carotid artery. Although administration of blood products is certainly not without risks and has become increasingly limited to the most severe situations in the ICU setting, the rates of life-threatening complications of transfusions are quite low, and reversal of severe thrombocytopenia or factor deficiencies may decrease the risk of CVC insertion-related bleeding in patients with severe coagulopathies. Thus, in my experience of working in an academic ICU with operators of varying experience (and many who think they are more experienced than they are) and in caring for a large number of oncology patients with bleeding dyscrasias, I maintain that the published www.chestpubs.org
data support the risk-to-benefit ratio favoring reversal of severe coagulopathies (eg, platelets , 50,000/mL and/or INR ⱖ 1.5, and/or PTT ⱖ 50 s) if time allows. Perhaps most importantly, inexperienced operators should be supervised by experienced proceduralists, and our hospital has now formalized the training protocol for line insertion and for supervision of lessexperienced operators in US-CVC (as have many other centers). Given that there is little that we can control in determining the outcomes of our sickest patients, why tempt fate when sticking needles into the necks of patients with coagulopathy without taking preventive measures to correct what might be a reversible risk? In other words, why take chances? Rebecca M. Baron, MD Boston, MA Affiliations: From the Pulmonary/Critical Care Division, Brigham and Women’s Hospital. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Rebecca M. Baron, MD, Pulmonary/Critical Care Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: [email protected] © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-3225
References 1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12): 1123-1133. 2. Central venous catheters—ultrasound locating devices: guidance. National Institute for Health and Clinical Excellence Web site. http://guidance.nice.org.uk/TA49/Guidance/pdf/ English. Published 2002. Updated 2005 and December 28, 2010. Accessed October 21, 2011. 3. Tercan F, Ozkan U, Oguzkurt L. US-guided placement of central vein catheters in patients with disorders of hemostasis. Eur J Radiol. 2008;65(2):253-256. 4. Rothschild JM. Ultrasound guidance of central vein catheterization. In: On Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: AHRQ Publications; 2001:245-255. http://www.ahrq.gov/clinic/ptsafety/chap21.htm. Accessed Otober 21, 2011. 5. Theodoro D, Krauss M, Kollef M, Evanoff B. Risk factors for acute adverse events during ultrasound-guided central venous cannulation in the emergency department. Acad Emerg Med. 2010;17(10):1055-1061. 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;253(1):249-252. 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;104(5):331-335. 8. Baombe JP, Sultan L. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. CHEST / 141 / 5 / MAY, 2012
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
1141
9. 10.
11. 12.
13.
14.
BET 3: central line insertion in deranged clotting. Emerg Med J. 2011;28(6):536-537. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg. 2007;204(4):681-696. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-417. Goodnough LT. Risks of blood transfusion. Anesthesiol Clin North America. 2005;23(2):241-252. Fiebig EW, Busch MP. Infectious risks of transfusion. In: Spiess BD, Spence RK, Shander A, eds. Perioperative Transfusion Medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:131-152. Stainsby D. ABO incompatible transfusions-experience from the UK Serious Hazards of Transfusion (SHOT) scheme Transfusions ABO incompatible. Transfus Clin Biol. 2005;1(2): 385-388. Toy P, Lowell C. TRALI—definition, mechanisms, incidence and clinical relevance. Best Pract Res Clin Anaesthesiol. 2007; 21(2):183-193.
Counterpoint: Should Coagulopathy Be Repaired Prior to Central Venous Line Insertion? No concept of “repairing a coagulopathy” is a comTheforting illusion. No one looks forward to insert-
ing a central venous line in a frail patient with an activated partial thromboplastin time greater than assay or an international normalized ratio (INR) of 10 or 12. Our “gut reaction” is to “fix” any abnormal laboratory value prior to placing a central venous line. Therefore, at first glance, the “con” position is counterintuitive and goes against the grain of many established cultural practices and reflexive responses in the hospital setting. These traditions have evolved with the good intention of following two wise mottos: (1) “safety first,” and (2) “primum non nocere.” Nevertheless, upon closer inspection, it turns out that the “cure” of a laboratory-diagnosed coagulopathy is usually elusive. The coagulopathy is usually a manifestation of the underlying disease that required hospitalization. The attempt to “repair” a laboratorydiagnosed coagulopathy can do more harm than the laboratory abnormality itself. That is why I am taking the “con” position in this debate, even though I anticipate that explaining my position will require swimming against the tide. For the purpose of this Point/Counterpoint Editorial, I am assuming that we are defining coagulopathies as abnormal laboratory tests that point to susceptibility to bleeding (eg, prolongation in the prothrombin time or partial thromboplastin time), not clotting. And I am taking an additional leap of faith by presuming that we are discussing primarily 1142
clinically ill patients who are hospitalized, not outpatients who are clinically stable. Among patients who require central venous lines, the surest route to managing the coagulopathy is to fix the underlying problem that is causing the laboratory abnormality. If the patient’s volume status is uncertain, the first step might be to measure the right atrial pressure with a central venous line, especially when clinical assessment (eg, neck surgery) is not feasible. The right atrial pressure measurement will help determine volume status and might help the physician decide whether to administer diuretics (in the presence of a high right atrial pressure) or whether to hydrate in the presence of a low right atrial pressure. Insertion of a central venous line to administer critical drugs through the catheter may be life saving. For example, coagulopathic patients who have septic shock require rapid treatment with multiple antibiotics through a central venous line. Other patients might be hypotensive and critically ill because of cardiogenic shock. They require prompt therapy with potent vasopressors, such as epinephrine, norepinephrine, phenylephrine, dopamine, or dobutamine, administered centrally. Another group of hypotensive patients in shock to consider are those with volume loss, who require rapid rehydration. In all three types of shock, delay in central venous line insertion could be deadly. In the hospital setting, ordering clotting factors or other medications to reverse a laboratory-diagnosed coagulation abnormality is time consuming (Fig 1). Consider the delay in communicating the order to the blood bank or pharmacy, filling the order, transporting the reversal agent to the patient’s bedside, administering the agent, and rechecking the coagulation parameter to determine whether, in fact, it has been normalized. Think of the possible roadblocks
Figure 1. The endless spiral of delay when attempting to “repair” a coagulopathy. Point/Counterpoint Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
the number of studies in the literature Although that address the question of coagulopathy rever-
sal prior to central venous catheter (CVC) insertion is small, and the question has been a difficult one to address with large trials, the issue is an extremely important one. Rather than operating based on experiential data and “gut feelings” (as we often do), a review of the existing literature in the context of my personal experience practicing in an ICU that cares for many patients with coagulopathy leads me to conclude that reversal of coagulopathy should be pursued prior to central line insertion (when feasible to do so). Given the increasing availability of peripherally inserted central catheters for more stable patients, the insertion of traditional central venous lines is increasingly used more exclusively in critically ill patients for monitoring and support in the ICU. Thus, the risk of any mechanical complication is heightened in critically ill patients with coagulopathy who have little reserve to tolerate additional hemodynamic derangements. I will first review the small pool of existing recent literature describing the risks of mechanical complications following central line insertion with ultrasound guidance; then, for comparison, I will briefly review the risks of life-threatening complications for patients after receipt of blood products for reversal of coagulopathy. Finally, I will conclude that the data support my experience and gut feelings that the riskto-benefit ratio for our critically ill patients favors reversing a coagulopathy prior to central line insertion. Risks of Central Line Insertion To frame the argument in favor of correction of coagulopathy prior to central line insertion, one must www.chestpubs.org
Point/Counterpoint Editorials
first assess the risks of CVC insertion and, in particular, the risk of mechanical complications that include arterial puncture, bleeding, and hematoma formation. Notably, mechanical complications occur in 5% to 19% of line insertions and vary with the site chosen for line insertion, with many reports suggesting that the femoral vein site has the highest overall rates of mechanical complication (especially arterial puncture and hematoma), followed by the subclavian vein site (especially pneumothorax and hemorrhage requiring transfusion), followed by the internal jugular (IJ) vein site as the lowest-risk site, with arterial puncture as the most frequent mechanical complication.1 Importantly, the risk of mechanical complications with CVC insertion has declined in recent years with the introduction of ultrasound-guided CVC insertion (US-CVC), and a number of professional societies have recommended US-CVC preferentially using the IJ location for both the relative safety of insertion at this site and the amenability of this site for ultrasound guidance.2-4 Thus, I will focus the rest of the debate in the context of US-CVC at the IJ site (even though this gives my opponent a substantial advantage, as this approach is now believed to be the safest overall approach in terms of minimizing mechanical complications). Even with use of US-CVC, studies still report significant mechanical complications, including bleeding, with a study from an academic medical center5 reporting a mechanical complication rate of close to 20% (Table 1).5-8 Although studies have identified different risk factors for bleeding with CVC, including severe coagulopathy, end-stage renal disease, very high or low BMI, dehydration, and number of needle passes required for successful cannulation, many studies identified inexperience of the operator as a critical risk factor for the development of mechanical complications. Interestingly, one recent study called into question the definition of an experienced operator, in that the highest risk of complications was observed in operators with intermediate levels of experience, whereas novice and senior operators exhibited less risk of complications.5 The authors speculate that novice operators were under the supervision of more senior operators, whereas intermediate operators might have been on their own and less experienced as the sole CHEST / 141 / 5 / MAY, 2012
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
1139
Table 1—Review of Literature Addressing US-CVC in Patients With Coagulopathy Study/Year, Location
Coagulopathic Insertions, No.
Study Design
Della Vigna et al /2009, 122 insertions (45 of these Italy deemed at high risk of bleeding); coagulopathy not corrected 6
Weigand et al7/2009, Germany
Tercan et al3/2008, Turkey
Theodoro et al5/2010, United States
Outcomes, Findings
Retrospective; interventional All CVCs placed on first radiology operators; pass; no bleeding; only subjects with cancer 3% of CVCs placed in IJ site (remainder in SCV site) 65 insertions (seven of these Prospective; operators No difference in significant with high risk of bleeding); with range of experience, bleeding in subjects with coagulopathy not corrected; including house officers; vs subjects without LMWH not administered heterogeneous patient coagulopathy; 88% of within 6 h of CVC insertion population CVCs placed in IJ site (2% SCV, 10% femoral) 133 insertions (80.5% with Prospective; experienced Association observed one coagulopathic parameter interventional radiology between elevated INR [ie, of plt, INR, or PTT operators; no correction ( . 1.5) and hematoma values]; 18% with two, and of coagulopathy development; 97% 1.5% with three parameters) undertaken prior of CVCs placed in IJ to CVC (1.5% SCV, 1.5% femoral) Prospective observational; Mechanical complications 43 insertions with INR ⱖ 2 operators with range of significantly higher in (15% of total insertions); experience, including subjects with ESRD and 33 insertions with ESRD house officers who for less-experienced (11% of total insertions) inserted ultrasound-guided operators; 19.7% overall IJ CVCs rate of mechanical complications (including 20 [6.9%] hematomas and 6 [2%] arterial punctures)
Comments No bleeding complications reported retrospectively with experienced operators inserting nontunneled lines Coagulopathy was not predictive of bleeding risk in the very small number of subjects who were coagulopathic INR elevation associated with bleeding risk, whereas platelet level, PTT, other factors were not in this study Difficult to discern overall number of subjects with coagulopathy; not known if subjects with ESRD were coagulopathic; supervision of less-experienced operators is important
CVC 5 central venous catheter; ESRD 5 end-stage renal disease; IJ 5 internal jugular; INR 5 international normalized ratio; LMWH 5 lowmolecular-weight heparin; plt 5 platelet; PTT 5 partial thromboplastin time; SCV 5 subclavian vein; US-CVC 5 ultrasound-guided central venous catheter insertion. (Adapted from Baombe et al.8)
or supervising proceduralists. Notably, this study was conducted in an academic ED and, thus, included analysis of US-CVCs from attending physicians as well as house officers with varying degrees of experience. Interestingly, even with experienced operators and the use of ultrasound, some studies have suggested that mechanical complications may be associated with severe thrombocytopenia (eg, platelet counts , 25,00050,000/mL) or an international normalized ratio (INR) ⱖ 1.5, or with multiple simultaneous coagulopathic derangements (eg, combinations of thrombocytopenia and factor deficiencies with INR ⱖ 1.5 and/or partial thromboplastin time [PTT] . 50 s).3,9 Some authors have argued that even if an arterial puncture is not a frequent event with IJ line insertion (reported as 6% in some studies), there exists the potential for significant risk of these punctures regardless of catheter size. Hematomas are reported to develop following as many as 40% of carotid punctures and can produce life-threatening bleeding if rapid expansion occurs, causing airway compromise. Additionally, carotid punctures pose the risk of development of a life-threatening cerebrovascular event from the need to compress the bleeding site adjacent to the carotid artery (especially in elderly patients with underlying vascular disease).9 Two studies that did not report an increase in bleeding risk with 1140
US-CVC were either retrospective studies6 or included only a small number of patients with coagulopathy,7 making definitive conclusions difficult (Table 1). Risks of Blood Product Infusion for Reversal of Coagulopathy In general, there has been a growing reluctance to transfuse blood products, unless absolutely indicated, especially within the ICU population, given increasing appreciation of possible immune-mediated events in addition to other traditional risks of blood product transfusion.10 However, the blood supply has never been safer in terms of risk of blood productacquired infections, and we must assess the relative risk of a blood product infusion vs the real risk of a mechanical complication related to US-CVC as described previously. Life-threatening risks from blood product administration are generally quite infrequent and can be divided into infectious and noninfectious risks (Table 2). Risks of HIV and hepatitis C are on the order of 1:2 million units transfused or less.11,12 Human error in administering a mismatched product occurs in 1:6,000 to 1:20,000 units, with massive hemolysis as a result of mismatch at a rate of 1:100,000 units.13 Transfusion-associated lung injury Point/Counterpoint Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
Table 2—Examples of Life-Threatening Risks of Blood Product Transfusion Approximate Incidence of Risk Occurrence
Risk of Transfusion Infectious risks: agent HIV Hepatitis C Bacterial infection (contaminated unit) West Nile virus (seasonal) Hepatitis B Noninfectious risks: event Acute hemolysis Anaphylaxis Human error causing mismatch Transfusion-associated lung injury
Approximate incidence per unit 1:2.4 million 1:2 million 1:1 million produces fatality from sepsis 1:350,000 1:200,000 Approximate incidence 1:50,000-1:100,000 1:30,000 1:6,000-1:20,000 1:2,000-1:4,000
(TRALI) is defined as new onset of acute lung injury within 6 h of transfusion not explained by an alternate cause and arises from donor antibodies reacting against the recipient endothelium, producing vascular leak. The risk of TRALI ranges from 1:2,000 to 1:4,000 units (which may be an underestimate due to underreporting), and though TRALI most often subsides spontaneously, it can produce serious consequences.14 Although risks of nonanaphylactic allergic transfusion reactions and volume overload are fairly common as a result of blood product transfusion, these are rarely life threatening. Summary/Conclusions CVC insertion, even with the use of ultrasound at the IJ site, carries a significant risk of mechanical complications. Although the absolute rate of complications is not easily discernible given the small number of studies in the literature and multiple complex factors that contribute to these risks, it is fairly well agreed upon that the employment of experienced operators leads to fewer mechanical complications. However, even in an optimal setting with a low rate of mechanical complications, a serious IJ site bleed can be life threatening given its location near the airway and carotid artery. Although administration of blood products is certainly not without risks and has become increasingly limited to the most severe situations in the ICU setting, the rates of life-threatening complications of transfusions are quite low, and reversal of severe thrombocytopenia or factor deficiencies may decrease the risk of CVC insertion-related bleeding in patients with severe coagulopathies. Thus, in my experience of working in an academic ICU with operators of varying experience (and many who think they are more experienced than they are) and in caring for a large number of oncology patients with bleeding dyscrasias, I maintain that the published www.chestpubs.org
data support the risk-to-benefit ratio favoring reversal of severe coagulopathies (eg, platelets , 50,000/mL and/or INR ⱖ 1.5, and/or PTT ⱖ 50 s) if time allows. Perhaps most importantly, inexperienced operators should be supervised by experienced proceduralists, and our hospital has now formalized the training protocol for line insertion and for supervision of lessexperienced operators in US-CVC (as have many other centers). Given that there is little that we can control in determining the outcomes of our sickest patients, why tempt fate when sticking needles into the necks of patients with coagulopathy without taking preventive measures to correct what might be a reversible risk? In other words, why take chances? Rebecca M. Baron, MD Boston, MA Affiliations: From the Pulmonary/Critical Care Division, Brigham and Women’s Hospital. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Rebecca M. Baron, MD, Pulmonary/Critical Care Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: [email protected] © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-3225
References 1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12): 1123-1133. 2. Central venous catheters—ultrasound locating devices: guidance. National Institute for Health and Clinical Excellence Web site. http://guidance.nice.org.uk/TA49/Guidance/pdf/ English. Published 2002. Updated 2005 and December 28, 2010. Accessed October 21, 2011. 3. Tercan F, Ozkan U, Oguzkurt L. US-guided placement of central vein catheters in patients with disorders of hemostasis. Eur J Radiol. 2008;65(2):253-256. 4. Rothschild JM. Ultrasound guidance of central vein catheterization. In: On Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: AHRQ Publications; 2001:245-255. http://www.ahrq.gov/clinic/ptsafety/chap21.htm. Accessed Otober 21, 2011. 5. Theodoro D, Krauss M, Kollef M, Evanoff B. Risk factors for acute adverse events during ultrasound-guided central venous cannulation in the emergency department. Acad Emerg Med. 2010;17(10):1055-1061. 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;253(1):249-252. 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;104(5):331-335. 8. Baombe JP, Sultan L. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. CHEST / 141 / 5 / MAY, 2012
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians
1141
9. 10.
11. 12.
13.
14.
BET 3: central line insertion in deranged clotting. Emerg Med J. 2011;28(6):536-537. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg. 2007;204(4):681-696. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-417. Goodnough LT. Risks of blood transfusion. Anesthesiol Clin North America. 2005;23(2):241-252. Fiebig EW, Busch MP. Infectious risks of transfusion. In: Spiess BD, Spence RK, Shander A, eds. Perioperative Transfusion Medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:131-152. Stainsby D. ABO incompatible transfusions-experience from the UK Serious Hazards of Transfusion (SHOT) scheme Transfusions ABO incompatible. Transfus Clin Biol. 2005;1(2): 385-388. Toy P, Lowell C. TRALI—definition, mechanisms, incidence and clinical relevance. Best Pract Res Clin Anaesthesiol. 2007; 21(2):183-193.
Counterpoint: Should Coagulopathy Be Repaired Prior to Central Venous Line Insertion? No concept of “repairing a coagulopathy” is a comTheforting illusion. No one looks forward to insert-
ing a central venous line in a frail patient with an activated partial thromboplastin time greater than assay or an international normalized ratio (INR) of 10 or 12. Our “gut reaction” is to “fix” any abnormal laboratory value prior to placing a central venous line. Therefore, at first glance, the “con” position is counterintuitive and goes against the grain of many established cultural practices and reflexive responses in the hospital setting. These traditions have evolved with the good intention of following two wise mottos: (1) “safety first,” and (2) “primum non nocere.” Nevertheless, upon closer inspection, it turns out that the “cure” of a laboratory-diagnosed coagulopathy is usually elusive. The coagulopathy is usually a manifestation of the underlying disease that required hospitalization. The attempt to “repair” a laboratorydiagnosed coagulopathy can do more harm than the laboratory abnormality itself. That is why I am taking the “con” position in this debate, even though I anticipate that explaining my position will require swimming against the tide. For the purpose of this Point/Counterpoint Editorial, I am assuming that we are defining coagulopathies as abnormal laboratory tests that point to susceptibility to bleeding (eg, prolongation in the prothrombin time or partial thromboplastin time), not clotting. And I am taking an additional leap of faith by presuming that we are discussing primarily 1142
clinically ill patients who are hospitalized, not outpatients who are clinically stable. Among patients who require central venous lines, the surest route to managing the coagulopathy is to fix the underlying problem that is causing the laboratory abnormality. If the patient’s volume status is uncertain, the first step might be to measure the right atrial pressure with a central venous line, especially when clinical assessment (eg, neck surgery) is not feasible. The right atrial pressure measurement will help determine volume status and might help the physician decide whether to administer diuretics (in the presence of a high right atrial pressure) or whether to hydrate in the presence of a low right atrial pressure. Insertion of a central venous line to administer critical drugs through the catheter may be life saving. For example, coagulopathic patients who have septic shock require rapid treatment with multiple antibiotics through a central venous line. Other patients might be hypotensive and critically ill because of cardiogenic shock. They require prompt therapy with potent vasopressors, such as epinephrine, norepinephrine, phenylephrine, dopamine, or dobutamine, administered centrally. Another group of hypotensive patients in shock to consider are those with volume loss, who require rapid rehydration. In all three types of shock, delay in central venous line insertion could be deadly. In the hospital setting, ordering clotting factors or other medications to reverse a laboratory-diagnosed coagulation abnormality is time consuming (Fig 1). Consider the delay in communicating the order to the blood bank or pharmacy, filling the order, transporting the reversal agent to the patient’s bedside, administering the agent, and rechecking the coagulation parameter to determine whether, in fact, it has been normalized. Think of the possible roadblocks
Figure 1. The endless spiral of delay when attempting to “repair” a coagulopathy. Point/Counterpoint Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on May 3, 2012 © 2012 American College of Chest Physicians