van de Weerdt Emma K, Biemond Bart J, Baake Bart, Vermin Ben, Binnekade Jan M, van Lienden Krijn P, Vlaar Alexander P J
Department of Intensive Care Medicine and the Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Amsterdam, the Netherlands.
Department of Hematology, Amsterdam, the Netherlands.
Transfusion. 2017 Oct;57(10):2512-2525. doi: 10.1111/trf.14248. Epub 2017 Aug 30.
Central venous catheters are frequently inserted into patients with coagulation disorders. It is unclear whether preprocedural correction of hemostasis is beneficial. We determined the incidence of bleeding complications after central venous catheter placement in patients who had severe coagulopathy and identified potential risk factors for bleeding.
The MEDLINE and Cochrane Library databases were systematically searched through November 2015. To be included, articles must have reported on hemorrhagic complications with specification of abnormal coagulation testing results. Severe coagulopathy was defined as a reduced platelet count of 50 × 10 /L or less, and/or an elevated international normalized ratio of 1.5 or greater, and/or a partial thromboplastin time of 45 seconds or greater.
We included one randomized controlled trial and 21 observational studies. In total, there were 13,256 catheter insertions, including 4213 in patients with severe coagulopathy. Before 3150 central venous catheter placements, coagulopathy was not corrected. The bleeding incidence varied from 0 to 32%. The severity of coagulopathy did not predict the risk of bleeding. No study demonstrated a beneficial effect from the prophylactic administration of platelets or fresh-frozen plasma to prevent bleeding complications. Retrospective observational studies suggested that no preprocedural correction is required up to a platelet count of 20 × 10 /L and an international normalized ratio of 3.0.
The incidence of major bleeding complications after central venous catheter placement is low, even in coagulopathic patients. Based on a systematic research of the literature, strong evidence supporting the correction of hemostatic defects before central venous catheter insertion is lacking. However, well-powered randomized controlled trials will be necessary to determine the minimal platelet count, the maximal international normalized ratio, and an activated partial thromboplastin time that is safe before central venous catheter insertion.
中心静脉导管常被插入凝血功能障碍患者体内。术前纠正止血是否有益尚不清楚。我们确定了严重凝血病患者中心静脉导管置入术后出血并发症的发生率，并确定了出血的潜在危险因素。
系统检索MEDLINE和Cochrane图书馆数据库至2015年11月。纳入的文章必须报告出血并发症，并明确异常凝血检测结果。严重凝血病定义为血小板计数降至50×10⁹/L或更低，和/或国际标准化比值升高至1.5或更高，和/或部分凝血活酶时间延长至45秒或更长。
我们纳入了1项随机对照试验和21项观察性研究。总共进行了13256次导管插入，其中4213次是在严重凝血病患者中进行的。在3150次中心静脉导管置入术前，未纠正凝血病。出血发生率从0%到32%不等。凝血病的严重程度不能预测出血风险。没有研究表明预防性输注血小板或新鲜冰冻血浆对预防出血并发症有有益效果。回顾性观察性研究表明，血小板计数高达20×10⁹/L和国际标准化比值为3.0时，术前无需纠正。
即使在凝血病患者中，中心静脉导管置入术后严重出血并发症的发生率也较低。基于文献的系统研究，缺乏支持在中心静脉导管插入术前纠正止血缺陷的有力证据。然而，需要有足够效力的随机对照试验来确定中心静脉导管插入术前安全的最低血小板计数、最高国际标准化比值和活化部分凝血活酶时间。
