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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 3  |  Page : 123-126

Central venous catheterization in patients with liver disease and coagulopathy


1 Department of Surgery, Isfahan University of Medical Sciences and Health Services, Isfahan, Iran
2 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
3 Shiraz Organ Transplant Center, Namazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
4 Department of General Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
5 Department of Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
6 Students Research Committee, School of Medicine, Isfahan University of Medical Sciences and Health Services, Isfahan, Iran

Date of Web Publication20-Dec-2017

Correspondence Address:
Dr. Shahab Shahabi
Isfahan University of Medical Sciences and Health Services, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_30_17

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  Abstract 


Background: Patients with end-stage liver disease frequently acquired complex disorders in hemostasis secondary to liver dysfunction. Objectives: This study aims to determine the incidence of vascular complications associated with central venous catheterization (CVC) in patients with coagulopathy and liver disease. Methods and Subjects: This multicentric, retrospective, cross-sectional study was performed on 993 patients undergoing liver transplantation who required central venous access (CVA) for their clinical management between October 2006 and October 2016. The age, sex, most recent platelet count, prothrombin time, international normalized ratio (INR), activated partial thromboplastin time, site of central venous catheter placement, and bleeding complications were retrieved from their medical records. Results: In these 993 cases, the mean age was 57.46 (standard deviation = 7.46) years, and 635 (63.9%) were male. Selected sites were the internal jugular (n = 889; 89.5%), subclavian (n = 93; 9.4%), and femoral (n = 11; 1.1%) veins. First attempt was successful in 925 cases (93.2%), in which 1 case had major bleeding, and 84 cases had minor bleeding. About 83% of the patients with liver failure take CVC procedure without any complications. None of the vascular complications occurred in 53% of the patients with low platelets and INR >1.5. Conclusion: We demonstrated major vascular complications following CVC in patients with liver disease and coagulopathy has low incidence in this audit. CVA procedures can be done safely in patients with disorders of hemostasis by skilled physicians who frequently perform these procedures.

Keywords: Central vein catheterization, liver transplantation, vascular complications


How to cite this article:
Sanei B, Shahabi S, Malek-Hosseini SA, Nikeghbalian S, Shamsaeifar A, Kakaei F, Kazemi K, Sheikhbahaei E. Central venous catheterization in patients with liver disease and coagulopathy. Indian J Transplant 2017;11:123-6

How to cite this URL:
Sanei B, Shahabi S, Malek-Hosseini SA, Nikeghbalian S, Shamsaeifar A, Kakaei F, Kazemi K, Sheikhbahaei E. Central venous catheterization in patients with liver disease and coagulopathy. Indian J Transplant [serial online] 2017 [cited 2020 Feb 19];11:123-6. Available from: http://www.ijtonline.in/text.asp?2017/11/3/123/221186




  Introduction Top


To manage various patients in current medical practice, central venous catheterization (CVC) has been increased.[1] In addition to its role in hemodynamic monitoring, central venous access (CVA) is frequently required for situations where peripheral venous access is not available for administrating chemotherapeutic agents, parenteral nutrition, hemodialysis, and stem cell transfusions.[2] Disorders of hemostasis are present in a large number of patients requiring CVA; in addition, patients with liver disease frequently develop complex disorders in hemostasis secondary to their disease.[3] Consequently, physicians are uncertain to perform these procedures due to high risk of bleeding and its complication.[4] Bleeding complications after central CVC may present as insertion site bleeding, subcutaneous hematoma, mediastinal hematoma, or hemothorax.[1],[2],[3],[4] There have not been any firm guidelines on CVC in the presence of coagulopathy although some series have suggested a low incidence of vascular complications.[1],[2],[3],[4] Moreover, it is unclear whether fresh frozen plasma or platelet concentrate should be given before any attempts. Finally, although correcting coagulopathy could be possible before this procedure, it may not be beneficial and it might be impossible to administer the corrective transfusion factor due to lack of venous access or the condition may not be correctableby transfusion alone.[5],[6],[7],[8],[9]

The literature on the safety of central line placement in patients with a bleeding diathesis is comprised mostly of small, single-center studies of heterogeneous populations undergoing central lines. We conducted this multicenter, retrospective study to identify factors predictive of bleeding complications from central venous catheterization in patients with underlying disorders of hemostasis and to determine the frequency and severity of these complications.


  Methods and Subjects Top


Patients

This retrospective cross-sectional study was performed on 993 patients undergoing liver transplantation who required CVA for clinical management between October 2006 and October 2016.

This study was approved by the Shiraz University Institutional Review Board, and all participants provided written informed consent to participate.

In this study, a retrospective analysis of the catheters placed over a 10-year period (2006–2016) was undertaken. During this period, all 993 catheters were placed percutaneously using Seldinger's technique. The sequential placement was right internal jugular vein, left internal jugular vein and if the initial site was unsuccessful, subclavian veins were next choice. All catheters were inserted by an anesthesiologist with transplantation fellowship.

The data extracted retrospectively from the medical records included age, sex, clinical diagnosis, most recent platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), and international normalized ratio (INR) and the occurrence of bleeding complications. The reference range for PT, aPTT, and platelets count in our laboratory was 10–13 s, 23–37 s, and 150–450 × 109/L, respectively. Patients with an INR more than 1.5 or platelets count <50 × 109/L were considered to have disorders of hemostasis.

Bleeding complications were recorded as significant when an intervention to stop the hemorrhage was undertaken. Bleeding that was controlled with manual digital pressure was not considered significant for analysis. Expanding subcutaneous hematomas on serial examination were considered significant. A postprocedure chest X-ray was obtained in each case, and any new opacity in the hemithorax or the mediastinal walls also considered a significant complication. The variables aPTT, INR, platelet count, and per catheter correction of coagulopathy were analyzed as potential factors predictive of bleeding complications. Data are presented as mean plus their standard deviation.


  Results Top


Total numbers of 993 patients were included in our study with the mean age of 57.46 (standard deviation [SD] = 7.46) years ranged between 1 and 63 years. Six hundred and thirty-five were males (63.9%) and 358 were females (36.1%).

Among 993 cannulation, the mean INR was 1.79 (SD = 1.60) (range: 1–12), mean platelet counts were 118 × 109/L (range: 6–445 × 109/L). They were divided into four groups: 469 (47.2%) patients with platelet counts more than 50,000/ml and INR <1.5, 167 (16.8%) of patients had abnormalities of both platelets and coagulation profile (platelet counts <50,000/ml and INR more than 1.5), 139 (14%) patients with platelet counts < 50,000/ml and INR <1.5, and 218 (22%) patients with platelet counts more than 50,000/ml and INR more than 1.5. Furthermore, no attempt was made to correct these episodes of coagulopathy with medications or infusion of blood products [Table 1].
Table 1: Central venous catheterization complication rate in patients with different platelet counts and international normalized ratio level

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The initial veins were the internal jugular (n = 889; 89.5%), subclavian (n = 93; 9.4%), and femoral (n = 11; 1.1%). First attempt was successful in 925 cases (93.2%). We found 1 case of major bleeding and 84 cases of minor bleeding. One patient had developed hemothorax after accidental subclavian artery puncture led to thoracotomy (INR was 1.55, platelets 98 × 109/L). There were no other major vascular complications. Thirty-one patients had cutaneous bleeding, and 53 patients developed small hematomas [Table 2]. Assessing hemorrhagic complications of four groups revealed minor vascular complications was highest in patients with abnormalities of both platelets and coagulation profile.
Table 2: Central venous catheterization complication rate according to their insertion sits

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  Discussion Top


In this study, we demonstrated that various vascular complications following CVC in patients with liver disease and coagulopathy occurred in few cases. In liver disease, having raised INR alone should not be considered an absolute contraindication of CVC. This study revealed that CVC procedures could be safely performed in patients with underlying disorders of hemostasis [Table 1]. Even patients with low platelet counts have rare bleeding complications, and these problems can be managed easily. In addition, the prophylactic correction of coagulation by transfusing blood products or coagulating factors is not necessary before CVC insertion and had debatable benefit. We suggested experienced clinicians using appropriate techniques can safely perform central venous catheterization in patients with abnormal PT, aPTT, and platelet counts. Randomized studies are necessary to achieve evidence-based approach to these complex situations.

Only a few studies have been determined the incidence of vascular complications associated with CVC procedure in patients with liver disease and coagulopathy especially in patients undergoing liver transplantation until now.

It is generally accepted that the platelet count should be >50 × 109/L before inserting a catheter.[10],[11],[12] Problems may arise when patients have platelets autoimmune disease such as idiopathic thrombocytopenic purpura or thrombotic thrombocytopenic purpura, or in the presence of deranged clotting, for example, in acute promyelocytic leukemia. The risks and benefits of insertion in terms of type and site of catheter must be assessed on an individual basis. When there is increased risk of bleeding or assuming difficulties in catheter insertion like in liver failure, using expert personnel and ultrasound guidance are essential [13] to maximize the rate of success in “ first pass” procedure without any further trauma. In addition lidocaine with adrenaline (epinephrine) 1:200,000 solution, as local anesthetic, can reduce subcutaneous bruising and bleeding. The increasing risks of blood product transfusion mandate individualized evaluation rather than routine correction of all minor abnormalities of platelet count and coagulation profile. If the patient has thrombocytopenia and there is evidence of bleeding after a catheter insertion, subsequently the patient should receive further platelet transfusion to maintain its count more than 50 × 109/L until bleeding stops. In these conditions, applying pushing dressings and topical tranexamic acid may help. Prolonged compression (15 min plus) often help stop the bleeding and should not be overlooked; however, there is no published prospective, randomized controlled trials to support or disprove the theory that the level of platelet count at time of central venous catheter (CVC) insertion should be maintained above 50 × 109/L to reduce the potential risk of significant bleeding problems.

Barrera et al.[14] revealed that thrombocytopenia is not the only risk factor for bleeding and determined that other variables such as insertion site, number of needle passes to cannulate the vein, and expertise are more pertinent. Similarly, the study by Ray and Shenoy concluded that periprocedural platelet transfusions have little effect on bleeding outcome. Other studies in patients with liver disease and complex hemostatic defects have found that a platelet count of <50 × 109/L was an independent risk factor for bleeding in comparison with raised INR or prolonged PT.[14],[15],[16],[17]

Our results support other literature addressing the rate of major hemorrhage with thoracic CVC among patients with thrombocytopenia or coagulopathy.[18],[19],[20],[21] These studies are quite heterogeneous, involving clinicians from different specialties, (surgery, anesthesia, and intensive care), variously sized catheters, anatomic landmark, and ultrasound-assisted approaches. These patients also had diverse indications for CVC and wide-ranging degrees of disordered hemostasis.

Similar to our study, Foster et al.[22] explored the risk of bleeding complications during percutaneous CVC in patients with coagulopathy, 40 liver transplant recipients underwent 259 percutaneous CVC. A total of 202 catheterizations were performed in patients with coagulopathy. No serious bleeding occurred during the 259 catheterizations.

In 2009, Weiqand et al. observed there were no significant differences in hemoglobin levels after catheter placement in 196 patients with and without severe disorders in hemostasis. These findings demonstrate that coagulation disorders with altered PT and INR or platelets did not increase the risk of significant bleeding when inserting a CVC. Therefore, the prophylactic correction of coagulation by transfusion of blood products or coagulating factors is not required before CVC insertion. In Mumtaz et al. study [23],[24] of 2010 CVC demonstrated 1,825 patients with a low platelet count (<50 × 109/L) had significantly higher bleeding complications. In comparison, in this study, a low platelet count was not the significant predictor of bleeding complication, and an abnormal aPTT and INR were not associated with bleeding complications. This observation is similar to other current studies.

According to our study, minor bleeding risks and rate due to CVC in patients with liver dysfunction showing the same results as other reports in this literature. Platelet counts below 50,000/μL have been shown to confer a small absolute risk (generally 5%) of minor bleeding at the catheter percutaneous insertion site, often controllable with direct pressure or occasionally a surgical stitch in the skin.[25],[26],[27],[28] Among our documented cases of minor hemorrhage, other intervention was uncommonly required. In recent randomized controlled trials of emergency and critical care units where ultrasonography was compared with anatomical and mark approaches contributed to improved success of initial thoracic CVC, with less attempts and reduced complications including arterial punctures.[28],[29],[30],[31]


  Conclusion Top


The low incidence of bleeding complications demonstrated in this study suggests that experienced clinician applying precaution, good technique, and correct patient positioning in their work can safely manage percutaneous CVC in patients with hemostasis disorders. Furthermore, there is no need to infuse blood products to correct the coagulopathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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