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Central venous catheterization in cancer patients with severe thrombocytopenia: Ultrasound-guide improves safety avoiding prophylactic platelet transfusion.

ABSTRACT: Prior research has revealed that ultrasound (US) guided central venous catheterization (CVC) is associated with a reduction in the complication rate such as pneumothorax and an improved first-pass success placing CVC in the internal jugular vein. The present study investigated if US-guided CVC, in a subset of cancer patients with severe thrombocytopenia, reduced bleeding risk and avoided prophylactic platelet transfusion. The efficacy and safety of US-guided CVC placement in cancer patients with severe thrombocytopenia was retrospectively analyzed over a period of 9 years (Dec 2000-Jan 2009), 1,660 and 207 patients with cancer underwent US-guided CVC placement into internal jugular vein respectively at the Department of Onco-Haematology, Hospital of Piacenza. The first group of patients included patients in active antitumor treatment, while the second group included patients in the palliative phase. A total of 110 (5.89%) of these 1,867 patients exhibited severe thrombocytopenia defined as platelet count ?20x109/l, and formed the basis of this study. All procedures were evaluated for bleeding complications as defined by the National Institute of Health Common Terminology Criteria for Adverse Events (CTCAE 3.0). In the subgroup of the 110 patients with severe thrombocytopenia a single needle puncture of the vein was employed in 121 of the 122 procedures (99.18%) and no attempt failures were registered. No pneumothorax, no major bleeding and no nerve and arterial puncture were reported, only one self-limiting hematoma (0.90%) at the site of CVC insertion was reported (CTCAE 3.0 grade 1). No platelet transfusions were performed in the 110 patients, pre and post CVC placement. We believe that US-guided CVC insertion procedures into the internal jugular vein makes the difference in safety, also in thrombocytopenic patients avoiding prophylactic or post procedure platelet transfusion.

SUBMITTER: Cavanna L

PROVIDER: S-EPMC7087476 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Central venous catheterization in cancer patients with severe thrombocytopenia: Ultrasound-guide improves safety avoiding prophylactic platelet transfusion.

Cavanna Luigi L Citterio Chiara C Nunzio Camilla Di D Orlandi Elena E Toscani Ilaria I Ambroggi Massimo M

Molecular and clinical oncology 20200305 5

Prior research has revealed that ultrasound (US) guided central venous catheterization (CVC) is associated with a reduction in the complication rate such as pneumothorax and an improved first-pass success placing CVC in the internal jugular vein. The present study investigated if US-guided CVC, in a subset of cancer patients with severe thrombocytopenia, reduced bleeding risk and avoided prophylactic platelet transfusion. The efficacy and safety of US-guided CVC placement in cancer patients with ...[more]

PMID: 32257200

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Project description:BackgroundLiver failure patients have traditionally been empirically transfused prior to invasive procedures. Blood transfusion is associated with immunologic and nonimmunologic reactions, increased risk of adverse outcomes and high costs. Scientific evidence supporting empirical transfusion is lacking, and the best approach for blood transfusion prior to invasive procedures in cirrhotic patients has not been established so far. The aim of this study is to compare three transfusion strategies (routine coagulation test-guided - ordinary or restrictive, or thromboelastometry-guided) prior to central venous catheterization in critically ill patients with cirrhosis.Methods/designDesign and setting: a double-blinded, parallel-group, single-center, randomized controlled clinical trial in a tertiary private hospital in São Paulo, Brazil.Inclusion criteriaadults (aged 18 years or older) admitted to the intensive care unit with cirrhosis and an indication for central venous line insertion. Patients will be randomly assigned to three groups for blood transfusion strategy prior to central venous catheterization: standard coagulation tests-based, thromboelastometry-based, or restrictive. The primary efficacy endpoint will be the proportion of patients transfused with any blood product prior to central venous catheterization. The primary safety endpoint will be the incidence of major bleeding. Secondary endpoints will be the proportion of transfusion of fresh frozen plasma, platelets and cryoprecipitate; infused volume of blood products; hemoglobin and hematocrit before and after the procedure; intensive care unit and hospital length of stay; 28-day and hospital mortality; incidence of minor bleeding; transfusion-related adverse reactions; and cost analysis.DiscussionThis study will evaluate three strategies to guide blood transfusion prior to central venous line placement in severely ill patients with cirrhosis. We hypothesized that thromboelastometry-based and/or restrictive protocols are safe and would significantly reduce transfusion of blood products in this population, leading to a reduction in costs and transfusion-related adverse reactions. In this manner, this trial will add evidence in favor of reducing empirical transfusion in severely ill patients with coagulopathy.Trial registrationClinicalTrials.gov, identifier: NCT02311985 . Retrospectively registered on 3 December 2014.

Project description:Patients with a low platelet count (thrombocytopenia) often require the insertion of central lines (central venous catheters (CVCs)). CVCs have a number of uses; these include: administration of chemotherapy; intensive monitoring and treatment of critically-ill patients; administration of total parenteral nutrition; and long-term intermittent intravenous access for patients requiring repeated treatments. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to CVC insertion, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to CVC insertion varies significantly from country to country. This indicates significant uncertainty among clinicians of the correct management of these patients. The risk of bleeding after a central line insertion appears to be low if an ultrasound-guided technique is used. Patients may therefore be exposed to the risks of a platelet transfusion without any obvious clinical benefit.To assess the effects of different platelet transfusion thresholds prior to the insertion of a central line in patients with thrombocytopenia (low platelet count).We searched for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2015, Issue 2), MEDLINE (from 1946), EMBASE (from 1974), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 23 February 2015.We included RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in patients of any age with thrombocytopenia requiring insertion of a CVC.We used standard methodological procedures expected by The Cochrane Collaboration.One RCT was identified that compared different platelet transfusion thresholds prior to insertion of a CVC in people with chronic liver disease. This study is still recruiting participants (expected recruitment: up to 165 participants) and is due to be completed in December 2017. There were no completed studies. There were no studies that compared no platelet transfusions to a platelet transfusion threshold.There is no evidence from RCTs to determine whether platelet transfusions are required prior to central line insertion in patients with thrombocytopenia, and, if a platelet transfusion is required, what is the correct platelet transfusion threshold. Further randomised trials with robust methodology are required to develop the optimal transfusion strategy for such patients. The one ongoing RCT involving people with cirrhosis will not be able to answer this review's questions, because it is a small study that assesses one patient group and does not address all of the comparisons included in this review. To detect an increase in the proportion of participants who had major bleeding from 1 in 100 to 2 in 100 would require a study containing at least 4634 participants (80% power, 5% significance).

Dataset Information

Central venous catheterization in cancer patients with severe thrombocytopenia: Ultrasound-guide improves safety avoiding prophylactic platelet transfusion.

Publications

Central venous catheterization in cancer patients with severe thrombocytopenia: Ultrasound-guide improves safety avoiding prophylactic platelet transfusion.

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