Central Venous Catheterization in Patients With Coagulopathy Preston F.

Foster, MD; Lucy R. Moore, RN, BSN; Howard N. Sankary, MD; Marquis E. Hart, MD; Marilyn K. Ashmann, RN, MSN; James W. Williams, MD

explore the risk of bleeding complications during perpatients with coagulopathy, 40 liver transplant recipients underwent 259

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cutaneous central venous catheterization in

venous catheterizations. Two hundred two catheterizations were performed in patients with coagulopathy, as evidenced by their prothrombin times, activated partial thromboplastin times, and/or platelet counts. Furthermore, no attempt was made to correct these episodes of coagulopathy with medications or infusion of blood products. No serious bleeding complications occurred during the 259 catheterizations, which suggests that experienced clinicians using appropriate techniques may safely perform central venous catheterization in patients with abnormal prothrombin times, activated partial thromboplastin times, and platelet counts.

percutaneous central

(Arch Surg. 1992;127:273-275)

are useful for hemodynamic administration of medications and parenteral Unfortunately, percutaneous in¬ sertion may result in bleeding complications, including in¬ sertion site bleeding, subcutaneous hematoma, mediastinal hematoma, and hemothorax.2 Although it seems logical that the risk of serious bleeding complications might be higher in patients with coagulopathy than in those without,3 the actual risk associated with percutaneous central venous catheter in¬ sertion in this circumstance may be quite low.4 Furthermore, because of the unsubstantiated fear of life-threatening bleed¬ ing complications in this clinical situation, many clinicians have opted for a variety of unproven, cumbersome, and pos¬ sibly harmful alternatives to the usual percutaneous inser¬ tion of central venous catheters. The purpose of this study is to determine the actual risk of serious bleeding complica¬ tions following percutaneous central venous catheterization in patients with varying degrees of coagulopathy.

catheters Central monitoring and the nutrition.1 venous

for

MATERIALS AND METHODS liver allograft recipients, who underwent 259 central catheter insertions between January 1988 and December 1988, were reviewed retrospectively. Prothrombin time (PT), ac¬ tivated partial thromboplastin time (APTT), and platelet (PLT) count were determined on the day of catheter insertion. The in¬ cidence of bleeding complications, including insertion site bleed¬ ing, hemothorax, mediastinal hematoma, and subcutaneous hematoma, were tabulated. The PT was determined with Quick's one-stage method5 us¬ ing the Medical Laboratory Automation Ine (Pleasantville, NY),

Forty

venous

Accepted for publication May 19,

1991. From the Department of General Surgery, Section of Transplantation Surgery, Rush\p=n-\Presbyterian\p=n-\StLuke's Medical Center, Chi-

cago, Ill.

Reprint requests to Department

of General

Surgery,

Section of Medical IL 60612

Transplantation Surgery, Rush\p=n-\Presbyterian\p=n-\StLuke's Center, 1653 W Congress Pkwy, 772 Jelke Bldg, Chicago, (Dr Foster).

700 Analyzer. Normal PT values range from 65% to 130% of control values in this coagulation laboratory. The APTT was de¬ termined with the same analyzer.6 Normal APTT values range from 21 to 31 seconds in this coagulation laboratory. The PLT count was determined with the Coulter (Miami Lakes, Fla) Model S analyzer. Phase microscopy with a Neubauer hemocytometer was performed if the PLT count was less than 35 X109/L by the automated method (Coulter). Normal PLT values range from 150 x 109/L to 399 x 109/L in this hematology laboratory. Insertion site bleeding was a hemorrhage that required removal of the catheter or surgical intervention, including placement of suture ligatures at insertion sites. Bleeding that was arrested with manual pressure was not considered significant and, therefore, was not tabulated as a bleeding complication. Hemo¬ thorax was a pleural opacity on a chest roentgenogram confirmed by aspiration of blood by thoracentesis. Mediastinal hematoma was a collection of blood in the mediastinum clinically evident from serial hematocrit concentrations, and confirmed by the appear¬ ance of an appropriate density on a chest computed tomogTam or roentgenogram. No attempt was made in this retrospective analysis to document subclinical hemothoraces and mediastinal hematomas. Subcutaneous hematoma was bleeding beneath the skin at the catheter insertion site that required surgical interven¬ tion to arrest bleeding or evacuate the clot. Percutaneous catheter insertion into the internal jugular (n 149 [58%]) and subclavian vein (n 110 [42%]) was accom¬ plished using Seldinger's technique.7 Insertion attempts were performed with a 16-gauge needle through which a 0.879-mmdiameter guide wire was passed into the punctured vessel. Over this wire, 8.5F (n 210 [81%]) or 7F (n 149 [19%]) catheters were inserted into the appropriate vessels. These large-caliber cathe¬ ters were chosen because of the need for hemodynamic monitor¬ ing with Swan-Ganz catheters, and the necessity of administration of fluids inherent to the perioperative care of the liver allograft recipient. The majority of these catheters (90% ) were inserted by physicians who had a minimum of 4 years of experience in central venous catheter in- sertion, and who had completed more than 100 successful attempts. Coagulopathy was an abnormality of the patient's PT, APTT, and/or PLT count. An abnormally low PLT was less than 80 x 109/L.8 An abnormally low PT was 40% of control or less.8 An abnormally prolonged APTT was 77 seconds or greater. No at¬ tempt was made to improve these coagulation abnormalities with infusion of blood products or medications before catheter insertion. Coagulation test values were classified into the fol¬ lowing four groups: "minimal" or absent coagulopathy, and cat¬ egories I through III coagulopathy. "Minimal" or absent coagu¬ lopathy was classified as a normal PT, APTT, and PLT count. In patients with category I coagulopathy, only one of these param¬ eters was abnormal; in category II, two parameters were abnor¬ mal; and in category III, three parameters were abnormal. =

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RESULTS Catheter insertions were performed in patients with cat¬ egory I (n 160), category II (n 40), and category III (n = 2) coagulopathy. Fifty-seven catheter insertions were per¬ formed in patients with normal coagulation test results ("minimal" coagulopathy). The average abnormal PT (n 122) was 29% of control (range, 39% to 10%). The aver=

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age abnormal APTT (n 3) was 92 seconds (range, 78 to 100 seconds). The average abnormal PLT count (n 122) was 47 x 109/L (range, 8 x 109/L to 79 x 107L). There were no bleeding complications in 259 insertions. Therefore, the incidence of bleeding complications was not different between attempts performed with or with¬ =

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