Prophylactic platelet transfusion and risk of bleeding associated with ultrasound‐guided central venous access in patients with severe thrombocytopenia

Abstract

Background: Reported risk of bleeding complications after central catheter access in patients with thrombocytopenia is highly variable. Current guidelines recommend routine prophylactic platelet (PLT) transfusion before central venous catheter placement in patients with severe thrombocytopenia. Nevertheless, the strength of such recommendations is weak and supported by observational studies including few patients with very low PLT counts (<20 × 10 9 /L). This study aims to assess the risk of bleeding complications related to using or not using prophylactic PLT transfusion before ultrasound-guided central venous access in patients with very low PLT counts. Methods:This was a retrospective cohort study of patients with very low PLT counts (<20 × 10 9 /L) subjected to ultrasound-guided central venous catheterization between January 2011 and November 2019 in a university hospital. Bleeding complications were graded according to the Common Terminology Criteria for Adverse Events. A multivariate logistic regression was conducted to assess the risk of major and minor bleeding complications comparing patients who did or did not receive prophylactic PLT transfusion for the procedure. Multiple imputation by chained equations was used to handle missing data. A two-tailed p < 0.05 was considered statistically significant.Results: Among 221 patients with very low PLT counts, 72 received prophylactic PLT transfusions while 149 did not. Baseline characteristics were similar between transfused and nontransfused patients. No major bleeding events were identified, while minor bleeding events were recognized in 35.7% of patients. Multivariate logistic regression analysis showed no significant differences in bleeding complications between patients who received prophylactic PLT transfusions and those who did not (odds ratio 0.83, 95% confidence interval 0.45-1.55, p = 0.567). Additional complete case and sensitivity analyses yielded results similar to those of the main analysis. Conclusions:In this single-center retrospective cohort study of ultrasound-guided central venous access in patients with very low PLT counts, no major bleeding was identified, and prophylactic PLT transfusions did not significantly decrease minor bleeding events.

Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care

“…Patients with unwitnessed cardiac arrest, initial presenting rhythm of asystole, or more than 3 hours from ROSC at enrollment were excluded. Study participants were randomized to 24 hours of mild hypercapnia (PaCO 2 50-55 mmHg) or normocapnia (PaCO 2 [35][36][37][38][39][40][41][42][43][44][45]. Despite achieving adequate separation in PaCO 2 values between groups, targeted mild hypercapnia did not result in improved neurologic outcomes at 6 months, the study's primary outcome (43.5% vs 44.6%, RR .98 [95% CI, .87-1.11]).…”

“…Bleeding following invasive procedures such as CVC insertion in patients with thrombocytopenia occurs frequently. 39,40 Guidelines regarding prophylactic platelet transfusion prior to CVC placement vary between 20 × 10 9 /L and 50 × 10 9 /L. 41,42 Use of ultrasound guidance for CVC insertion decreases the risk for bleeding.…”

Pre‐central venous catheter insertion platelet count: How low can you go?

“…In the recent retrospective cohort study by Zarama et al, 1 221 patients with thrombocytopenia (platelets < 20 × 10 9 /L) underwent ultrasound-guided central venous catheter (CVC) insertion. Seventytwo of those patients received prophylactic platelet transfusions and 149 did not.…”

Authors’ reply to Siegel, AM and McCurdy, MT. “Pre–central venous catheter insertion platelet count: How low can you go?

“…In our single-center retrospective cohort, routine prophylactic platelet transfusions were not associated with significant reductions of minor bleeding complications, while no major bleeding events were identified. 1 Imputation and multiple sensitivity analyses were conducted aiming to handle missing data and to assess multiple associations between some relevant clinical variables and predetermined clinical outcomes. Although robustness of the findings retrieved from multiple imputation models was confirmed and different sensitivity analyses yielded the same results, we recognized important limitations that could limit the external validity of our conclusions.…”

“…Siegel and McCurdy for their interest in our manuscript on prophylactic platelet transfusions in patients with severe thrombocytopenia subjected to ultrasound‐guided central venous catheterization (US‐CVC). In our single‐center retrospective cohort, routine prophylactic platelet transfusions were not associated with significant reductions of minor bleeding complications, while no major bleeding events were identified 1 . Imputation and multiple sensitivity analyses were conducted aiming to handle missing data and to assess multiple associations between some relevant clinical variables and predetermined clinical outcomes.…”