Dr. Meyer
Clinical question: Can central venous catheters (CVC) be safely placed in patients with platelet counts less than 50,000 without administration of platelets prior to the procedure?
Background: Thrombocytopenia is a common clinical condition in patients with critical illness and the presence of thrombocytopenia can increase the risk of bleeding complications around procedures. The reported risk of bleeding from central line placement in patients with thrombocytopenia is low, but the quality of evidence is poor and there is a lack of consensus on how to manage thrombocytopenia in the context of central line placement. Additionally, expanded use of ultrasound may have reduced the risk of bleeding complications with central line placement.
Study design: Multi-center, randomized, non-inferiority trial
Setting: 10 hospitals in the Netherlands
Synopsis: A total of 373 central lines were placed during the study; eligible patients were undergoing ultrasound-guided placement of a CVC in a hematology ward or intensive care unit with a platelet count between 10,000 and 50,000 per mcL. Patients on anticoagulation or receiving a peripherally inserted central catheter (PICC) were excluded. Patients were randomized in a 1:1 fashion to receive either a prophylactic platelet transfusion prior to the procedure or no transfusion. The primary outcome was the rate of procedure-related bleeding. Catheter-related bleeding was significantly lower in the group that received a prophylactic transfusion (4.8%) compared to those receiving no transfusion (11.9%) (RR, 2.45; 90% CI, 1.27 to 4.70). A total of 13 severe bleeding events occurred, with only four in the transfusion group. There were only two transfusion reactions. Given the limited supply of platelets, the authors recommend a tailored approach with transfusion given preferentially to those with rapidly declining platelet counts or platelet counts closer to 10,000 to 20,000. Limitations include not reporting rates of aspirin or other anti-platelet use and lack of full blinding.
Bottom line: Administration of prophylactic platelet transfusion prior to CVC placement is likely to reduce the risk of bleeding for patients with pre-existing thrombocytopenia. Particular consideration for transfusions should be given to those with more severe thrombocytopenia and dropping platelets, however, local approaches should consider the available platelet supply in their decision making.
Citation: van Baarle FLF, et al. Platelet transfusion before CVC placement in patients with thrombocytopenia. N Engl J Med. 2023;388(21):1956-65.
Dr. Meyer is vice chair of clinical affairs and quality in the department of medicine, and hospital medicine attending, at Maine Medical Center, Portland, Maine, and an assistant professor at Tufts University School of Medicine, Boston.