CVK vid defekt hemostas

Fredrik Öberg

Bitr överläkare

Anestesikliniken

Karolinska Solna

fredrik.oberg@karolinska.se

2

SFAI riktlinjer 2011

3

Vad är man rädd för?

Stor blödning med fatal utgång

Sällsynt

Svårt att studera

Koagulopati?

Andra faktorer?

Sivande blödning

Hematom

4

KS 2013

Kärlet identifieras ua med ultraljud

Punktion ua, ultraljudslett, skarp nål, venöst backflöde

J-ledaren ner i kärlet ua, dock lite mer motstånd än normalt

Koll med rtg-genomlysning, J-ledaren ser ut att ligga rätt

Hudstick + tunnelering av slang ua (med ledaren på plats)

Dilatator + hylsa träs ner över ledaren

Klart mer motstånd än normalt, ”fick ta i lite”

Pat klagar på att det känns konstigt att andas

Dilatator ut (hylsan kvar)

5

… KS 2013

Oklart om blodretur via hylsan, ”fingret på” direkt

Bums ner med katetern genom hylsan

Kunde ej flusha eller aspirera

Kallade på hjälp

Tittade, kollade med rtg-genomlysning, katetern såg ut att ligga rätt

Drog långsamt ut slang och aspirerade samtidigt – ingen retur

Till slut kom hela slangen ut

Beslut – stick om!

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… KS 2013

Pat klagar på att det känns konstigt att andas

Pat blir tachykard

” Hmm… nån konstig arytmi eller….? ”

Går runt och kollar patienten

Pat likblek, blir medvetslös

… trycker på larmknappen

… HLR

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Danmark 1996-2004

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…Danmark

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USA 1970-2000

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USA

103 fall

wire/catheter embolus (n 20), cardiac tamponade (n 16),

carotid artery puncture/cannulation (n 16), hemothorax (n 15),

and pneumothorax (n 14)

Nearly half of the central catheter claims were judged as

possibly preventable…

…by either ultrasound guidance or pressure waveform

Coagulopathy?

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Sverige 1999-2008

Anders Larsson, Gävle, opubl data

Lex Maria- , HSAN- och Patientskadeärenden

10 dödsfall

Allvarliga brister i teknik och handläggning

I ett ärende diskuteras hemostasdefekt som möjlig bidragande

orsak

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SFAI riktlinjer 2011

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SFAI riktlinjer 2011

1500 artiklar

100 intressanta abstracts

54 granskade artiklar

Sedan dess: Ytterligare 10

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SFAI riktlinjer 2011 Ref nr

Publ year

N (nr of catheters)

Study design and Setting

Catheter type and cannulation site

Ultrasound used

Purpose and/or methods Outcome Comment

Weigand K et al. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters.

1 2009 196 Open prospective, nonrandomized. 2xICU 1XHemathology HDU

Dialysis Std 3-lumen IJV 88% SCV 10% FV 2%

Yes - Two groups, with cutoff at PLT=50 and/or INR=1,5. - Analysed for bleeding, measured as Hb-drop > 1,5 g/dl post CVC insertion.

- 58 of 196 pat had coagulopathy - No difference between groups - 34 pats (17,4%) had Hb-drop > 1,5, 7 of which in coagulopathy group - No major bleeding (i.e. other than oozinghematoma).

- Quite a lot of bleeding in this study! - Hb-drop > 1,5 is a rather crude measure of oozing/haematoma. - None of those with both PLT<50 and INR>1,5 had a Hb-drop. This suggests choice of safer technique and/or experienced operator for those with the most severe coagulopathy

Lee AC. Elective removal of cuffed central venous catheters in children.

2 2007 N/A Literature study Tunneled catheters N/A Study of complications from removal of cuffed lines, both adults and children. Recommendations stated for children.

Air embolism most common complication. No bleeding.

Interesting

Stecker MS et al. Time to hemostasis after traction removal of tunneled cuffed central venous catheters.

3 2007 179 Open? Prospective nonrandomized

Cuffed tunneled cvc, jugular or femoral.

N/A To study correlation between abnormal coag studies (PT, INR, APTT, PLT) and time to hemostasis after traction removal.

- 44 of 179 pat had PLT<50 and/or INR>1.5. - No correlation between coag studies and time to hemostasis. -End stage renal failure, antiplatelet agents, and low-volume operator correlated with prolonged time to hemostasis. -92% had hemostasis within 5 min. Only one patient took more than 15 min.

- Pats with “severely abnormal coag” was excluded (APTT>100s, INR>4, PLT<10, heparin infusion) - Unclear whether patient characteristics were known by operators (choice of techniquie/operator affected by pat characteristics?) - Presumably all these catheters had been there for quite a while, therefore no conclusions can be drawn about removal of newly put in catheters (i.e. those without a fibrin sheath around them).

Tercan F et al. US-guided placement of central vein catheters in patients with disorders of hemostasis.

4 2008 133 Open Prospective, case series

- IJV 97% - 18 G needle - 12F (n=106), 7F (n=21), 6F (n=6)

Yes To study the frequency of bleeding (=oozing and/or hematoma) in a group of patients having PLT≤50 and/or INR≥1,5 and/or APTT≥50s.

- No major bleeding. - 3,8% oozing, 1,5% hematoma, 0,8% both. - Mean PLT=30.6, INR=3.1, APTT=70s

- No arterial punctures in entire series - 100% success rate. - Mean no of attempts 1,01. - Very experienced operators, all lines placed by only two radiologists with 8 and 5 years of experience on US-guided CVC placement

Lozano M et al. Platelet transfusion in thrombotic thrombocytopenic purpura: between Scylla and Charybdis-

6 2005 71+78 Two case series TTP Patients

“Plasma exchange catheters”, mostly subclavian route

Not stated Paper refers to two case studies of patients with TTP, total of 149 patients

Two deaths from hemorrhage, both subclavian punctures, unclear if ultrasound

- Bad choice of technique and puncture site for coagulopathic patients? Author had no data on the use of ultrasound (e-mail correspondence)

Neunert CE et al. Implantable central venous access device procedures in haemophilia patients without an inhibitor: systematic review of the literature and institutional experience.

7 2005 N/A Review CVC and ports Not stated General guidelines on CVC and ports in hemophiliacs

“Always give factor concentrates prior to insertion if possible”

Segal JB, Dzik WH; Transfusion Medicine/Hemostasis Clinical Trials Network. Paucity of studies to support that abnormal coagulation test results predictbleeding in the setting of invasive procedures: an evidence-based review.

8 2005 N/A Literature study Various invasive Not stated Is pathologic INR / PT predictive of There is not sufficient Covers bronchoscopy, CVC, Femoral angiography, liver biopsy or

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INR (leversvikt)

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…leversvikt

658 kanyleringar

INR 1 – 17

TPK 9 – 1088

30 artärpunktioner

En hemothorax efter artärstick i subclavia (TPK 68)

Cutoff för sivande blödn / hematom

TPK<50

INR > 5

…internal jugular cannulation, more than one needle pass into

the vein, failure to pass any guidewire, high INR, low platelets,

heparin therapy

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Heparin 1991

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…heparin

516 kanyleringar

252 fullhepariniserade

22 artärpunktioner

22 hematom

13 med heparin

9 utan heparin

… av 22 artärpunktioner

12 med heparin, 10 utan

7 hematom – 4 med heparin, 3 utan

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TPK

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…TPK

133 kanyleringar

TPK 2.29 – 49 (medel 30.6)

100 % success rate

Inga artärpunktioner

No major bleeding

8 oozing / hematoma / both

2 (glada) interventionister

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Etc…

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Etc

Invasive linte placement in critically ill patients: Do hemostatic

defects matter?

Should plasma be transfused prophylactically before invasive

procedures

etc.…..

2014:

Bleeding complications of central venous catheterization in

septic patients with abnormal hemostasis

….

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Sammanfattning

Stor blödning

Endast vid allvarlig brist i teknik och handläggning

Inga stora blödningar pga koagulopati vid korrekt handläggning

Hemostasdefekt kan bidra (?)

Sivande blödning / hematom

Dålig korrelation med labprover

Kombinationer (läkemedel, övriga faktorer)

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Praktiska råd

Anamnes

Prover aldrig rutinmässigt

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Praktiska råd

Optimera sällan

Aldrig rutinmässigt

Tänk på hela patienten (och mindre på anestesiologen)

Vid misstänkt hemostasdefekt:

Erfaren operatör

Säker teknik

Avbryt eller ändra strategi vid problem

Övervakning post op

Tunnelerade katetrar och venportar

Korrigera vid behov (och om möjligt) som vid medelstor kirurgi

(APTT 1.3 x ref, TPK 50, INR 1.8, …)

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Praktiska råd

Friläggning är inte visat bättre än stick

Tänk på patienten och inte på anestesiologen