CVK vid defekt hemostas - sfai.se · 3 Vad är man rädd för? Stor blödning med fatal utgång...
Transcript of CVK vid defekt hemostas - sfai.se · 3 Vad är man rädd för? Stor blödning med fatal utgång...
CVK vid defekt hemostas
Fredrik Öberg
Bitr överläkare
Anestesikliniken
Karolinska Solna
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!
6
… 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
17
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?
18
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
20
SFAI riktlinjer 2011
1500 artiklar
100 intressanta abstracts
54 granskade artiklar
Sedan dess: Ytterligare 10
21
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
23
…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
25
…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
27
…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
29
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
….
30
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)
32
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, …)