Category: Critical Care
Keywords: Central Lines, Platelets, Bleeding (PubMed Search)
Central Venous Catheter (CVC; aka central line) placement is a common procedure in both the ED and ICU, and while overall quite safe, does carry some risk. In particular, many of us regularly are confronted with the challenge of placing a line in a patient with profound thrombocytopenia, which can result in significant bleeding. In these cases, should we give platelets before we place the line?
Van Baarle et al published a randomized study in NEJM comparing an empiric 1u platelet transfusion vs no transfusion in patients with a platelet count of 10,000-50,000, prior to line placement. The study included both HD and non-HD (e.g. TLC) lines, from all three major access sites, in patients in their ICU or hematology ward. They found statistically fewer serious bleeding events in the transfusion group (4.8%) vs no transfusion group (11.9%). The study wasn't powered to look at more patient oriented outcomes like mortality, but I'm sure we can all agree less bleeding is probably a good thing. Also importantly, this study did not evaluate the risks/benefits of delaying line placement to obtain platelets when the line is urgently needed, so I would not recommend extending this to conclude platelets must be given before line placement if the line is needed for something highly time-sensitive (e.g. only available access to infuse pressors in a hypotensive patient).
Bottom Line: It is probably beneficial and appropriate to provide prophylactic platelet transfusion prior to CVC placement in patients with a platelet count less than 50,000, assuming circumstances allow.
van Baarle FLF, van de Weerdt EK, van der Velden WJFM, Ruiterkamp RA, Tuinman PR, Ypma PF, van den Bergh WM, Demandt AMP, Kerver ED, Jansen AJG, Westerweel PE, Arbous SM, Determann RM, van Mook WNKA, Koeman M, Mäkelburg ABU, van Lienden KP, Binnekade JM, Biemond BJ, Vlaar APJ. Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia. N Engl J Med. 2023 May 25;388(21):1956-1965. doi: 10.1056/NEJMoa2214322. PMID: 37224197.