#3 Journal Club: Platelets Before Central Lines?

Join Nick & Cyrus as they take on their first journal club episode! This week the duo provides their take on the NEJM paper from van Baarle and colleagues entitled Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia. They also provide some of their tips and tricks for safe central line placement. Give it a listen and let us know what you think!

Outline

1. Our review & reaction to recent papers

2. Is the study a “high quality study”?

3. Is this “practice changing” or “practice affirming”?

4. Nick’s approach to literature review:

1. First - look at the methods

1. Is the population relevant to your practice?

2. Is the study applicable to your population?

2. Next the figures

1. … including those in the supplements

3. Then the results

1. … especially those that are NOT release with the main paper

5. Cyrus’s approach to literature review:

1. Abstract first: Is this worth my time? Is this relevant?

1. Nick reminds us that often in high-end journals, the abstract isn’t written by the authors

2. Methods to determine the research population

3. Results

4. Discussion

5. Supplements
   
   

1. The Paper - the basics

1. Question: Should we transfuse platelets in patients prior to placing a central venous line (CVC) in thrombocytopenia (10-50K)

2. Primary outcome: Occurrence of “grade II” or higher bleeding

1. Grade I: bleeding stopped with minimal interventions

2. Grade II: > 20 min bleeding

3. Grade III: Intervention required to stop bleeding, but no shock

4. Grade IV: Hemodynamic instability relating to CVC insertion + bleeding complication

3. Patients: ICU & Hematology/Oncology Patients

1. Did not include many patients with liver or kidney disease (see supplemental appendix), who are classically at a higher bleeding risk 

4. Single blinded, multi-center, RCT in Europe

5. Patients received either 1U PLT or nothing prior to the procedure

6. Operators were “experienced” 

7. Groups were stratified in the paper by trial center & catheter type, not by where the catheter was placed

8. Non-inferiority trial: Testing that not giving PLT was non-inferior to giving PLT!

1. Withholding PLT before central line insertion is no-worse than giving PLT before a central line!
   
   

2. What did they find?

1. 372 CVC placements

2. Grade II-IV bleeding in 9 / 188 patients who received PLT & 22 / 185 patients in non-transfused group, a significant findings

3. So… withholding PLT was NOT non-inferior… so giving PLT could be superior, but this study was NOT designed to make that argument!
   
   

3. Our assessment

1. Most patients were hematology/oncology patients (higher risk than the average), many subclavian line placements (non-compressible site)

2. Figure 2: bleeding occurrence / risk seemingly driven by those patients who:

1. …were on the hematology/oncology ward or…

2. … were recipients of subclavian lines

3. No difference with/without PLT for IJ lines!

4. Question: is it well-advised to place a CVC in a non-compressible site in a high risk patient? - NO!

5. It’s not surprising that providing PLT in these patients that had a relatively high-bleeding-risk procedure done… mitigated risk! But this begs the question, should we routinely take this approach in the first place?!

3. Experience:

1. The paper discusses “experienced” operators - but this definition is extremely variable and subjective

2. Paper: Experience = 50+ CVC placements

1. Is 50 lines over the course of a career vs 50 lines within a year or two the same? Probably not!

2. Problematic definition given the potential heterogeneity.

4. Take always:

1. Don’t place high-risk subclavian lines if you can avoid it

2. You probably don’t need to transfuse platelets to mitigate bleeding risk in less risky lines (such as internal jugular CVCs)

3. Always think about applicability and whether the interventions performed match your own tendencies
   
   

4. Easter Egg(s): CVC Insertion Pearls from Nick & Cyrus

   1. Dilate ALONG the wire, not against it - this avoids bending the wire

   2. Make the skin-incision LARGE enough for you to actually insert the dilator without bluntly traumatizing the skin

   3. Make the incision CLOSE to the wire to avoid skin-bridges

   1. Wiggle the wire following incision to break up any skin-bridges you do create

   2. Consider a purse string suture around your line if you’ve made TOO generous of a skin incision

   4. “Floss” your wire while advancing the dilator - this makes sure the wire moves freely within the dilator lumen and isn’t getting bent by the dilator

   5. For larger lines: consider using ONE dilation (the smaller dilator) instead of two sequential dilations - this can provide a “snugger” catheter fit and also reduces soft-tissue trauma

   6. Micropuncture kits:

   1. A smaller needle (21g vs 18g) than the standard CVC needle, which may provide better control, reduce bleeding risk and reduce risk of hematoma formation

   2. Helpful in the coagulopathic patient, or higher risk insertions

   7. Holding pressure

   1. If there is bleeding… a minute-to-two of pressure may be all you need!

   2. Be deliberate, direct with your pressure - 1 or 2 fingers over the bleeding site is much more effective than a big wad of gauze!

   8. Uremic patients

   1. Consider given DDAVP and PLT transfusion in these individuals

Audio

Video

• References

  Van Baarle, Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia, NEJM 2023

• RCTs Discussed

  3SITES (NEJM 2015)