Archived Comments for:
Percutaneous tracheostomy in patients with severe liver disease and a high incidence of refractory coagulopathy: a prospective trial
Coagulopathic disorders are very common in ICU patients and often times are touted as absolute or relative contraindications to numerous invasive procedures commonly performed among this group of patients due to a perception of possible increased risk of bleeding complications
Apart from liver disease, which happens to be the culprit cause of coagulopathy in the study by Auzinger et al., other common causes include severe sepsis, disseminated intravascular coagulation and deliberate anticoagulation of patients.
Common procedures of interest in the critical care unit include central venous cannulation, tracheostomy, hemodialysis access placement and certain drainage procedures. The most studied of all the above vis-à-vis haemostatic complication is central venous cannulation.
In his study of central venous catheterization in patients with coagulopathy secondary to liver disease, Foster et al noted no serious bleeding in 259 catheterizations out of which 202 were coagulopathic as evidenced by their prothrombin times, activated partial thromboplastin times, and/or platelet counts. (1) In this study, no attempts were made to correct the coagulopathy either by use of procoagulant medications or transfusion of blood products. Foster et al therefore concluded that “experienced clinicians using appropriate techniques may safely perform central venous catheterization in patients with documented coagulopathy.
Doerfler et al (2) also arrived at the same conclusion. In both studies, skilled or experienced physicians were defined as physicians who frequently performed these procedures.
The most feared complication of central venous catheter placement is inadvertent arterial perforation. “Experience” in this case not only has to do with frequently applied skills in catheterization technique (which leads to a reduction in number of attempts. unsuccessful catheterizations, line infections) but most importantly on adequate appreciation of normal as well as possible variations in landmarks and surface anatomy relevant to the procedure (which leads to a reduction in inadvertent arterial perforation). In summary, if you do not puncture the subclavian artery or repeatedly traumatize the subclavian vein during the process of catheterization, the presence of a coagulopathy becomes essentially irrelevant. The importance of adequately appreciating the surface anatomy cannot be over emphasized. Because of variations in landmarks and patient sizes as well as errors inherent in human nature, experience in this instance is to a certain extent a limited asset. This is why some centers prefer the practice of sonographic or fluoroscopic guided procedures. Not minding the above published studies, most clinicians would still be cautious by attempting to correct underlying coagulopathy prior to performing these procedures irrespective of the skill set available.
In the study by Auzinger et al., the absence of significant bleeding in the group of patients with refractory coagulopathy cannot be entirely attributed to the experience of the performers of the percutaneous dilational tracheostomy. (PDT)
First and foremost, the risk of catastrophic bleeding in PDT is inherently low because of its atraumatic nature and the absence of any major vascular bundles in or close to the operating field.
Secondly any inherent bleeding risk may have been masked by attempting (successfully or unsuccessfully) to correct the underlying coagulopathy prior to the tracheostomy.
The decision to correct or not to correct an underlying coagulopathy in a critically ill patient prior to any invasive procedure should be made on a case by case basis bearing in mind the overall risk of the specific procedure as well as each patient’s peculiar circumstances.
As concluded by the authors, I would not hesitate to provide adequate clotting support most of the time.
References
1. Foster PF, Moore LR, Sankary HN, Hart ME, Ashmann ML, Williams JW: Central venous catheterization in patients with caogulopathy. Arch Surg. 1992 Mar;127(3):273-5
2. Doerfler ME, Kaufman B, Goldenberg AS: Central venous catheter placement in patients with disorders of hemostatsis. Chest 1996 Jul:110(1):185-8
Critical Care
Coagulopathies and Invasive ICU Procedures
24 October 2007
Coagulopathic disorders are very common in ICU patients and often times are touted as absolute or relative contraindications to numerous invasive procedures commonly performed among this group of patients due to a perception of possible increased risk of bleeding complications
Apart from liver disease, which happens to be the culprit cause of coagulopathy in the study by Auzinger et al., other common causes include severe sepsis, disseminated intravascular coagulation and deliberate anticoagulation of patients.
Common procedures of interest in the critical care unit include central venous cannulation, tracheostomy, hemodialysis access placement and certain drainage procedures. The most studied of all the above vis-à-vis haemostatic complication is central venous cannulation.
In his study of central venous catheterization in patients with coagulopathy secondary to liver disease, Foster et al noted no serious bleeding in 259 catheterizations out of which 202 were coagulopathic as evidenced by their prothrombin times, activated partial thromboplastin times, and/or platelet counts. (1) In this study, no attempts were made to correct the coagulopathy either by use of procoagulant medications or transfusion of blood products. Foster et al therefore concluded that “experienced clinicians using appropriate techniques may safely perform central venous catheterization in patients with documented coagulopathy.
Doerfler et al (2) also arrived at the same conclusion. In both studies, skilled or experienced physicians were defined as physicians who frequently performed these procedures.
The most feared complication of central venous catheter placement is inadvertent arterial perforation. “Experience” in this case not only has to do with frequently applied skills in catheterization technique (which leads to a reduction in number of attempts. unsuccessful catheterizations, line infections) but most importantly on adequate appreciation of normal as well as possible variations in landmarks and surface anatomy relevant to the procedure (which leads to a reduction in inadvertent arterial perforation). In summary, if you do not puncture the subclavian artery or repeatedly traumatize the subclavian vein during the process of catheterization, the presence of a coagulopathy becomes essentially irrelevant. The importance of adequately appreciating the surface anatomy cannot be over emphasized. Because of variations in landmarks and patient sizes as well as errors inherent in human nature, experience in this instance is to a certain extent a limited asset. This is why some centers prefer the practice of sonographic or fluoroscopic guided procedures. Not minding the above published studies, most clinicians would still be cautious by attempting to correct underlying coagulopathy prior to performing these procedures irrespective of the skill set available.
In the study by Auzinger et al., the absence of significant bleeding in the group of patients with refractory coagulopathy cannot be entirely attributed to the experience of the performers of the percutaneous dilational tracheostomy. (PDT)
First and foremost, the risk of catastrophic bleeding in PDT is inherently low because of its atraumatic nature and the absence of any major vascular bundles in or close to the operating field.
Secondly any inherent bleeding risk may have been masked by attempting (successfully or unsuccessfully) to correct the underlying coagulopathy prior to the tracheostomy.
The decision to correct or not to correct an underlying coagulopathy in a critically ill patient prior to any invasive procedure should be made on a case by case basis bearing in mind the overall risk of the specific procedure as well as each patient’s peculiar circumstances.
As concluded by the authors, I would not hesitate to provide adequate clotting support most of the time.
References
1. Foster PF, Moore LR, Sankary HN, Hart ME, Ashmann ML, Williams JW: Central venous catheterization in patients with caogulopathy. Arch Surg. 1992 Mar;127(3):273-5
2. Doerfler ME, Kaufman B, Goldenberg AS: Central venous catheter placement in patients with disorders of hemostatsis. Chest 1996 Jul:110(1):185-8
Competing interests
None