Transfusion policies may negatively affect outcomes after central catheter placement
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Key takeaways:
- Patients with severe thrombocytopenia who did not receive prophylactic transfusion before catheter placement had more catheter-related bleeding events.
- Prophylactic transfusion resulted in a net cost increase.
Withholding prophylactic platelet transfusion before placement of a central venous catheter in patients with severe thrombocytopenia resulted in more catheter-related bleeding events, results of a randomized noninferiority trial showed.
Withholding transfusion also did not meet the study’s predefined margin for noninferiority when compared with administering transfusion prior to catheter placement among individuals with a platelet count of 10,000 to 50,000/mm2.
The findings, published in The New England Journal of Medicine, suggested that not all patients should be managed with the same strategy, as those treated on a hematology ward who did not receive prophylactic transfusions before central venous catheter (CVC) placement had significantly higher risk for a catheter-related bleeding event than those who received CVCs in an ICU setting, the investigators noted.
“Withholding prophylactic platelet transfusion prior to CVC placement in [patients with] severe thrombocytopenia leads to more catheter-related bleedings,” Alexander Vlaar, MD, PhD, MBA, head of the intensive care unit at Amsterdam University Medical Center, told Healio. “We can use the results of the study to develop a more personalized approach.”
Background
Blood transfusions are not “innocent interventions” and carry with them the potential for negative effects if not deployed properly, according to Vlaar.
“In many areas, it has been shown to be safe to apply a restrictive blood transfusion policy,” he said. “The optimal transfusion [platelet] threshold in patients undergoing an intervention in the setting of severe thrombocytopenia is unclear, and transfusion guidelines provide contradicting recommendations.”
Methodology
The multicenter, randomized noninferiority PACER trial examined whether prophylactically transfused platelets effectively prevent CVC-related bleeding in patients with severe thrombocytopenia, defined as a platelet count of 10,000 to 50,000/mm2.
The per-protocol primary analysis included data on 373 CVC placements among 338 patients. Investigators randomly assigned participants being treated in either a hematology clinic or ICU in a 1:1 ratio to receive either 1 U of prophylactic platelet transfusion (n = 188; median age, 58 years; interquartile range [IQR], 47-65; 33.5% women) or no transfusion (n = 185; median age, 59 years; IQR, 50-65; 37.8% women) before ultrasound-guided CVC placement.
Grade 2 to grade 4 catheter-related bleeding served as the study’s primary outcome measurement.
Key findings
Investigators reported that 4.8% of patients in the transfusion group had grade 2 to grade 4 catheter-related bleeds compared with 11.9% in the nontransfusion group (RR = 2.45; 90% CI, 1.27-4.7).
Grade 3 or grade 4 catheter-related bleeds occurred in 2.1% of those who received prophylactic transfusions compared with 4.9% among those who did not (RR = 2.43; 95% CI, 0.75-7.93).
A secondary analysis showed the risk for grade 2 to 4 CVC-related bleeding increased as platelet counts decreased.
Subgroup analyses revealed higher bleeding risk among those treated in a hematology ward compared with those treated in the ICU (RR = 2.99, 95% CI, 1.19–7.54).
Thirteen grade 3 catheter-related bleeding events occurred during the study, including four in the transfusion group and nine in the nontransfusion group.
Researchers calculated a net savings of $410 per catheter placement by withholding prophylactic platelet transfusion prior to the procedure.
Clinical implications
The results of the PACER trial should have an impact on clinical practice because they are broadly applicable yet underline the need for a personalized approach, according to Vlaar.
“We would advocate to use prophylactic platelet transfusion in hematology patients with severe thrombopenia and not in ICU patients prior to CVC placement,” he told Healio. “Furthermore, we do see a lower risk for catheter-related bleeding in the jugularis location compared with femoral or subclavian. This should also be considered when balancing the risk vs. benefit of a transfusion.”
The results are the latest in researchers’ attempts to determine the optimal transfusion thresholds for patients with anemia and thrombocytopenia, Vlaar said, adding that previous trials have shown restrictive transfusion practices to be safe.
“This trial is one of the first to show there is a lower limit to restricting blood transfusions in patients prior to undergoing an intervention,” he said. “There are still many other settings where the lower limits for blood transfusion need to be established.”
For more information:
Alexander Vlaar, MD, PhD, MBA, can be reached at a.p.vlaar@amsterdamumc.nl.
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