van de Weerdt E K, Peters A L, Goudswaard E J, Binnekade J M, van Lienden K P, Biemond B J, Vlaar A P J
Department of Intensive Care Medicine, Academic Medical Centre, Amsterdam, The Netherlands.
Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.), Academic Medical Centre, Amsterdam, The Netherlands.
Vox Sang. 2017 May;112(4):343-351. doi: 10.1111/vox.12498. Epub 2017 Mar 5.
Correction of coagulopathy prior to central venous catheter (CVC) placement is advocated by guidelines, while retrospective studies support restrictive use of transfusion products.
We conducted a mixed vignette and questionnaire web survey to investigate current practice and preferences for CVC placement. Clinical vignettes were used to quantify the tendency to administer platelet concentrate. A positive ß-coefficient is in favour of administering platelet concentrate.
Ninety-seven physicians answered the survey questions (36 critical care physicians, 14 haematologists, 20 radiologists and 27 anaesthesiologist). Eighty-six physicians subsequently completed the clinical vignettes (response rate 71%). Preferences in favour of correcting thrombocytopenia prior CVC placement were platelet counts of 10 × 10 /L and 20 × 10 /L (ß = 3·9; ß = 3·2, respectively), the subclavian insertion site (ß = 0·8). An elevated INR (INR = 3; ß = 0·6) and an elevated aPTT (aPTT = 60 s; ß = 0·4) showed a positive trend towards platelet transfusion. Platelet transfusion was less likely in an emergency setting (ß = -0·4). Reported transfusion thresholds for CVC placement varied from <10 × 10 /L to 80 × 10 /L for platelet count, from 1·0 to 10·0 for INR and from 25 s to 150 s for aPTT. Implementation of ultrasound guidance as standard practice was limited.
Current transfusion practice prior to CVC placement is highly variable. Physicians adjust the decision to correct coagulopathy prior CVC placement based on clinical parameters, insertion site and technique applied.
指南提倡在放置中心静脉导管（CVC）前纠正凝血功能障碍，而回顾性研究支持限制使用输血产品。
我们进行了一项混合式案例和问卷调查的网络调查，以探究当前CVC放置的实践情况和偏好。临床案例用于量化给予血小板浓缩液的倾向。正的β系数有利于给予血小板浓缩液。
97名医生回答了调查问题（36名重症监护医生、14名血液科医生、20名放射科医生和27名麻醉医生）。随后86名医生完成了临床案例（回复率71%）。支持在CVC放置前纠正血小板减少的偏好情况为血小板计数10×10⁹/L和20×10⁹/L（β分别为3.9和3.2）、锁骨下插入部位（β = 0.8）。国际标准化比值（INR）升高（INR = 3；β = 0.6）和活化部分凝血活酶时间（aPTT）升高（aPTT = 60秒；β = 0.4）显示出血小板输注的积极趋势。在紧急情况下血小板输注的可能性较小（β = -0.4）。报告的CVC放置的输血阈值，血小板计数从<10×10⁹/L到80×10⁹/L不等，INR从1.0到10.0不等，aPTT从25秒到150秒不等。作为标准操作实施超声引导的情况有限。
目前CVC放置前的输血实践差异很大。医生根据临床参数、插入部位和应用的技术来调整在CVC放置前纠正凝血功能障碍的决定。
