Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia

Floor L F van Baarle; Emma K van de Weerdt; Walter J F M van der Velden; Roelof A Ruiterkamp; Pieter R Tuinman; Paula F Ypma; Walter M van den Bergh; Astrid M P Demandt; Emile D Kerver; A J Gerard Jansen; Peter E Westerweel; Sesmu M Arbous; Rogier M Determann; Walther N K A van Mook; Mirelle Koeman; Anja B U Mäkelburg; Krijn P van Lienden; Jan M Binnekade; Bart J Biemond; Alexander P J Vlaar

doi:10.1056/NEJMoa2214322

Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia

N Engl J Med. 2023 May 25;388(21):1956-1965. doi: 10.1056/NEJMoa2214322.

Authors

Floor L F van Baarle¹, Emma K van de Weerdt¹, Walter J F M van der Velden¹, Roelof A Ruiterkamp¹, Pieter R Tuinman¹, Paula F Ypma¹, Walter M van den Bergh¹, Astrid M P Demandt¹, Emile D Kerver¹, A J Gerard Jansen¹, Peter E Westerweel¹, Sesmu M Arbous¹, Rogier M Determann¹, Walther N K A van Mook¹, Mirelle Koeman¹, Anja B U Mäkelburg¹, Krijn P van Lienden¹, Jan M Binnekade¹, Bart J Biemond¹, Alexander P J Vlaar¹

Affiliation

¹ From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands.

PMID: 37224197
DOI: 10.1056/NEJMoa2214322

Abstract

Background: Transfusion guidelines regarding platelet-count thresholds before the placement of a central venous catheter (CVC) offer conflicting recommendations because of a lack of good-quality evidence. The routine use of ultrasound guidance has decreased CVC-related bleeding complications.

Methods: In a multicenter, randomized, controlled, noninferiority trial, we randomly assigned patients with severe thrombocytopenia (platelet count, 10,000 to 50,000 per cubic millimeter) who were being treated on the hematology ward or in the intensive care unit to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement. The primary outcome was catheter-related bleeding of grade 2 to 4; a key secondary outcome was grade 3 or 4 bleeding. The noninferiority margin was an upper boundary of the 90% confidence interval of 3.5 for the relative risk.

Results: We included 373 episodes of CVC placement involving 338 patients in the per-protocol primary analysis. Catheter-related bleeding of grade 2 to 4 occurred in 9 of 188 patients (4.8%) in the transfusion group and in 22 of 185 patients (11.9%) in the no-transfusion group (relative risk, 2.45; 90% confidence interval [CI], 1.27 to 4.70). Catheter-related bleeding of grade 3 or 4 occurred in 4 of 188 patients (2.1%) in the transfusion group and in 9 of 185 patients (4.9%) in the no-transfusion group (relative risk, 2.43; 95% CI, 0.75 to 7.93). A total of 15 adverse events were observed; of these events, 13 (all grade 3 catheter-related bleeding [4 in the transfusion group and 9 in the no-transfusion group]) were categorized as serious. The net savings of withholding prophylactic platelet transfusion before CVC placement was $410 per catheter placement.

Conclusions: The withholding of prophylactic platelet transfusion before CVC placement in patients with a platelet count of 10,000 to 50,000 per cubic millimeter did not meet the predefined margin for noninferiority and resulted in more CVC-related bleeding events than prophylactic platelet transfusion. (Funded by ZonMw; PACER Dutch Trial Register number, NL5534.).

Publication types

Equivalence Trial
Multicenter Study
Randomized Controlled Trial

MeSH terms

Catheterization, Central Venous* / adverse effects
Catheterization, Central Venous* / methods
Hemorrhage / etiology
Hemorrhage / prevention & control
Humans
Platelet Count
Platelet Transfusion* / methods
Thrombocytopenia* / diagnosis
Thrombocytopenia* / therapy
Ultrasonography, Interventional

Associated data

NTR/NL5534

Grants and funding

843002625/ZONMW_/ZonMw/Netherlands