Central Line for plasmapheresis in TTP

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redy

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We recently had a patient with TTP with platelets in 10000s. The next step was to put a central line for plasmapheresis. Obviously with that low platelets it is a pretty high risk scenario.

So my question is where would you put it?

I thought femoral would be the right option as a its easier, more room if there is bleeding, and compressible if there is bleeding. However the attending put it in IJ.

What have you guys done/would do?

Thanks guys.
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redy said:
We recently had a patient with TTP with platelets in 10000s. The next step was to put a central line for plasmapheresis. Obviously with that low platelets it is a pretty high risk scenario.

So my question is where would you put it?

I thought femoral would be the right option as a its easier, more room if there is bleeding, and compressible if there is bleeding. However the attending put it in IJ.

What have you guys done/would do?

Thanks guys.
Click to expand...

IJ

Wouldn't have thought twice
 
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How are you going to compress it with the carotid beside?

And if there was a hematoma would it not have a pressure effect on the carotid as there would not be room to expand?

Thanks for the answers so far. Just trying to understand it.

Sent from my Nexus 7 using Tapatalk 2
 
Femoral risk would be an RP bleed- definitely not compressible.
 
why would the carotid bleed uncontrolled with a platlet count of 10K. Would it? Should it? I would honestly be more worried about coagulopathy but the real question for you is "what platelet count precludes central line placement? "

Is there an ABSOLUTE platelet threshold for line placement? What about a chest tube? What about paracentesis/thoracentesis?

Each line placement site has its own complications. I have never NOT been able to compress an IJ. The brain has bilateral blood flow, in addition thee pressure required to compress the IJ is much less than that needed to compress a carotid.

I have also had large neck hematomas from venous bleed which,,although unsightly and embarassing, have not affected airway nor mental status of my patients.
 
Further, with the advent of ultrasound for guidance I would think the incidence of carotid sticks would be near zero for the experienced operator.
 
ok.got it. Thanks guys for the replies.
 
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K31 said:
Oh, so true. I once held pressure for two hours on a femoral puncture site in a coagulopathic variceal bleed patient after the intern dilated the artery.
Click to expand...

just use a femstop for something like that.
 
the best line when you have a patient which is coagulpathic or at risk of bleeding is an ultrasounded guided IJ.

i learned this the hard way on my vascular surgery rotation responding to consults. FEmorals can be deadly. Holding pressure on the neck is absolutely no biggie. Even if you hit the carotid, you can just hold pressure. In the femoral, on the other hand, it is easy to accidently poke too high and hit or backwall iliac and then it's game over
 
redy said:
How are you going to compress it with the carotid beside?

And if there was a hematoma would it not have a pressure effect on the carotid as there would not be room to expand?

Thanks for the answers so far. Just trying to understand it.

Sent from my Nexus 7 using Tapatalk 2
Click to expand...

Why would the pressure required to stop a venous bleed occlude an artery?


On the iPad
 
There is no risk to carotid holding pressure for bleeding vein
 
The venous hematoma would at tamponade or diffuse through a fascial plane long before it could ever compress an artery. Think about what kind of pressures it would take for it to compress the artery (you would literally need pressures above the map- which would mean blood was flowing backwards out of he right heart...)

I a rurally haven't though about manual compression causing any issue. I suppose if someone has carotid plaque burden they could start to shower- never seen it though.
 
I think you're getting some good anecdotal advice. However, I tend to take the opposite tack. The neck hematoma with airway compromise is the main complication your have to worry about in this case. It's rare (Never happened to me, but I know of at least 2 separate instances in the last 7 years at my program where this happened) but it can kill the patient really quickly. Conversely, I've never seen someone die from an rp or thigh hematoma from a cvc stick. I do think an u/s guided IJ is pretty safe anyway and certainly is appropriate, particularly if the patient is already intubated (who cares about a neck hematoma then). However, if you believe the current en vogue data, the infection rates for femoral and ij lines are pretty similar, furthermore you can still use u/s guidance and if you know where to stick for a femoral line you can still hold pressure. So if someone is supercoagulopathic, in dic etc, plt<10,000 and int > 4 and fiibrongen <100, etc I'd probably put in a femoral. Just make sure you don't stick high. But again, if someone is more comfortable with an IJ, needed a cvp, or the patient had favorable neck anatomy, I don't see anything wrong with an IJ. I would not put a shiley in the axillary or subclavian vein or do a subclavian stick on for any line on a coagulopathic patient.
 
late entry here. 10k plts is chump change IMO. I dropped in an US guided IJ as in intern in leukemia pt with plt count of <1. Basically i think she had A circulating platelet lol. I was on general med call, the surgeon on call was called by ICU for a line, he is not at all trained with US and flatly refused to put in anything with that high of a risk for bleeding as the pt was not crashing but just needed multiple access ports and potentinally a pressor if she turned foer the worse. I had rotated with him earlier that year and have a good relationship with him. ICU team called me and asked if I would put in an IJ and I said sure. Took 8 minutes, one stick. No bleeding other than some superficial skin bleeding which a 22 in the hand would have also caused. Surgeon stood there and watched me and said 'ya know, after 35+ years of being a surgeon and seeing all the advances you would think I would have learned how to use one of these, meh I am retiring soon". No joke.

In agreement with JDH and others, hard to compress the groin and RP bleeds are killers. I stick the groin for emergent and I mean emergent access. They are essentially coding in front of you with no access. Infection rate is 3-4x IJ. Good luck compressing the chest in a subclavian bleed if your pts are half as fat as mine. Unless I am really tired and dont feel like waiting for the NS to fetch the US and thus throw in a subclavian, we are small community and dont have our own :(, everyone gets an US guided IJ. In all cases. with an US on the neck it is virtually impossible to drop a lung and should very rarely if ever result in a carotid stick. Neck is alot thinner than the chest or upper thigh, alot easier for the med student to get their hands around it to compress it :p
 
Holding pressure on an IJ shouldn't be a problem. The issue is if someone isn't really as well trained at US as they think and somehow dilate the carotid.
 
I would place an ultrasound-guided IJ line over either a subcl or a femoral line. The target is gigantic on ultrasound and it is highly likely that (with US) you'll get access in one stick.

Even when I visualize the stick with US, I still confirm venous prior to dilating by either: (1) visualizing the guide wire in the IJ by using the probe in a longitudinal access, or (2) transducing. If you confirm placement of an angiocath then there is no way that you'll mistakenly dilate a carotid artery. It takes an extra 30 seconds.

The only time that I skip the confirmation step is for either a quasi-coding or coding patient. My hope is that U/S training becomes both routine and more sophisticated for residents. Once you are facile with an ultrasound machine, it is truly helpful.
 
Idiot07..... I'm a surgeon and I do a lot of vascular. Trust me.... Retroperitoneal bleeding is common and deadly in a coagulopathic patient and not uncommon from fem sticks.

Second.... A neck hematoma is never going to be a problem if your patient is already intubated. And rarely will be an issue for non intubated if venous.


Furthermore..... Say I'm wrong and you create some massive neck venous hematoma which proves me wrong and compresses the neck anatomy so much that an already intubated patient is at risk for whatever reason....

No problem.... I can still open that hematoma at bedside and take this person to the operating room. With a retroperitoneal bleed.... All bets off. Nothing I can do surgically.

That's the difference.

If patient is coagulopathic and really needs a line and you aren't a surgeon then I highly suggest you consult your vascular surgery colleagues before you attempt a femoral line. Cuz you really shouldn't be doing them.
 
Not YOU shouldn't be doing any lines... I meant one shouldn't be doing femoral lines in coagulopathic patient who doesn't have contraindication to IJ
 
souljah1 said:
Even when I visualize the stick with US, I still confirm venous prior to dilating by either: (1) visualizing the guide wire in the IJ by using the probe in a longitudinal access, or (2) transducing. If you confirm placement of an angiocath then there is no way that you'll mistakenly dilate a carotid artery. It takes an extra 30 seconds.
Click to expand...

I agree that it would be exceedingly rare, and I've never done it myself, but I have seen it happen. I don't know if they visualized in a longitudinal plane or transduced. I wouldn't say it would never happen though. Someone could have carotid disease or be in a dissection plane or be against a wall or some other reason for dampening which could alter the pressure waveform. Crazy things can always happen, I just consider myself lucky that it hasn't happened to me.
 
Europeman,

I am a surgery resident. PGY-5

We put in a lot of lines. I don't know how many at this point. I would estimate >500. Who knows and who cares.

See my post about a neck hematoma not causing a problem in an intubated patient. I agree with you on that.

In an unintubated patient a neck hematoma can be a problem. Again, hasn't happened to be me, but has happened to 2 people I know who were solid residents using u/s in difficult necks. I doubt it was from vein. I suspect there was some sort unrecognized carotid stick, the lines were in the vein, The carotid wasn't dilated. No big hematoma at time of placement. Then 30 min to an hour later patient has unstable airway and dies. Even if it doesn't cause a problem you're gonna be pretty nervous for a while.

They didn't open up the neck hematoma in either case, but I think this is going to be easier said than done, as opposed to bleeding from a carotid endarectomy or thyroidectomy where you can just cut the suture line and the deep space is open. This is going to be an epic flail if the patient survives.

I think you guys are overstating the risk of an rp bleed. Again if you stick the groin in the right place the risk of rp bleed is essentially 0, you'll get a thigh or groin hematoma, and teh artery and vein are compressible. If for some reason you stick femoral artery and it bleeds into the rp that isn't that hard to control surgically, You have a small hole in the femoral arery in the groin. The rp hematoma you can't cotnrol surgically are spontaneous ones from lumbars and such. Besides they almost all stop and tamponade off as soon as coagulopathy is corrected. In the mean time the bleeding would be slow and you could keep up with transfusions...... and you're not slashing somebodies neck open at bedside. I say would and could cause, again I can't remember this happening from a cvc, I'm sure it has, but most of the time I've seen after a cardiac cath where where there was a dilator in the artery or it's spontaneous. If you want to talk about uncontrollable the perforation of the L IJ/ SCV confluence via a dilator would be much worse.

Whoever said femorals had a 3-4 higher infection rate than IJ's. That's just not true

Ann Intern Med. 2012 Nov 20;157(10):JC5-8. doi: 10.7326/0003-4819-157-10-201211200-02008.
Review: Femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections.
Whalen F.


That being said. If the patient described above had a normal iNR and didn't have hostile neck anatomy, I'd put in the IJ, but again I think a femoral line is an reasonable choice in an unintubated or squirrelly supercoagulopathic patient
 
Last edited:
I think our experience mirrors a lot of others here. We always have access to an ultrasound and our go-to line is the US guided IJ. We become very proficient at it and I feel very comfortable using it folks with low plts or slightly elevated INR. If you're proficient with US and take your time then your chances of hitting carotid should be extremely low. Usually first thing I do is just take the probe and look at both sides of the neck first. Most of the time we do right, but have run across times where the IJ was extremely small compared to the left or was sitting directly on the carotid and just felt more comfortable going on the left due to anatomy.

We hardly do femorals anymore, save for the active code with no access. Most of the time if we're doing a line we also want CVP and ScVO2 capabilities.

Also not doing as many subclavians anymore, usually reserved for if a line is emergently needed and US not available or we can't touch the neck. Certainly wouldn't do one in this scenario. Did do one with US guidance though that was interesting....

And I've had similar experiences with surgeons not having US experience. We actually taught one of our surgeons how to use US for IJs.
 
idiot07 said:
Europeman,

I am a surgery resident. PGY-5

We put in a lot of lines. I don't know how many at this point. I would estimate >500. Who knows and who cares.

See my post about a neck hematoma not causing a problem in an intubated patient. I agree with you on that.

In an unintubated patient a neck hematoma can be a problem. Again, hasn't happened to be me, but has happened to 2 people I know who were solid residents using u/s in difficult necks. I doubt it was from vein. I suspect there was some sort unrecognized carotid stick, the lines were in the vein, The carotid wasn't dilated. No big hematoma at time of placement. Then 30 min to an hour later patient has unstable airway and dies. Even if it doesn't cause a problem you're gonna be pretty nervous for a while.

They didn't open up the neck hematoma in either case, but I think this is going to be easier said than done, as opposed to bleeding from a carotid endarectomy or thyroidectomy where you can just cut the suture line and the deep space is open. This is going to be an epic flail if the patient survives.

I think you guys are overstating the risk of an rp bleed. Again if you stick the groin in the right place the risk of rp bleed is essentially 0, you'll get a thigh or groin hematoma, and teh artery and vein are compressible. If for some reason you stick femoral artery and it bleeds into the rp that isn't that hard to control surgically, You have a small hole in the femoral arery in the groin. The rp hematoma you can't cotnrol surgically are spontaneous ones from lumbars and such. Besides they almost all stop and tamponade off as soon as coagulopathy is corrected. In the mean time the bleeding would be slow and you could keep up with transfusions...... and you're not slashing somebodies neck open at bedside. I say would and could cause, again I can't remember this happening from a cvc, I'm sure it has, but most of the time I've seen after a cardiac cath where where there was a dilator in the artery or it's spontaneous. If you want to talk about uncontrollable the perforation of the L IJ/ SCV confluence via a dilator would be much worse.

Whoever said femorals had a 3-4 higher infection rate than IJ's. That's just not true

Ann Intern Med. 2012 Nov 20;157(10):JC5-8. doi: 10.7326/0003-4819-157-10-201211200-02008.
Review: Femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections.
Whalen F.


That being said. If the patient described above had a normal iNR and didn't have hostile neck anatomy, I'd put in the IJ, but again I think a femoral line is an reasonable choice in an unintubated or squirrelly supercoagulopathic patient
Click to expand...
Read through all your posts and I agree with Idiot07 completely (maybe you should change your name??!! lol)...

I had a colleaugue place an IJ line in a coagulopathic unintubated patient once....Patient got intubated hours later for progressive hematoma and airway compromise. You don't have to dilate the carotid for this to happen, even a carotid stick could seep blood hours... I would be very wary of doing an IJ line in such a patient...

Secondly, I also agree complete that the risk of retroperitoneal bleed is being totally overstated on this thread.... I have done many a femoral lines, on coagulopathic and non-coagulopathic patients alike.... They get a GROIN hematoma...which is usually harmless, but worst thing most times is loss of distal leg pulses...

I hope everyone understands why subclavian is out of the question....

And to the people who are saying that an experienced ultrasound user would be okay to do an IJ and get it in one stick... I say to them: If anything was 100%, we wouldnt be having this conversation at all... Just go ahead and put in a subclavian then, since it's all about experience with technique and with identifying veins on ultrasound.... No doubt experience plays a huge role, and I wouldn't let a 1st year critical care fellow place this line...but we also know it goes beyond that.
 
souljah1 said:
I would place an ultrasound-guided IJ line over either a subcl or a femoral line. The target is gigantic on ultrasound and it is highly likely that (with US) you'll get access in one stick.

Even when I visualize the stick with US, I still confirm venous prior to dilating by either: (1) visualizing the guide wire in the IJ by using the probe in a longitudinal access, or (2) transducing. If you confirm placement of an angiocath then there is no way that you'll mistakenly dilate a carotid artery. It takes an extra 30 seconds.

The only time that I skip the confirmation step is for either a quasi-coding or coding patient. My hope is that U/S training becomes both routine and more sophisticated for residents. Once you are facile with an ultrasound machine, it is truly helpful.
Click to expand...
How do you transduce before dilating? Place a temporary angiocath?
 
Exactly use an angiocath. It's just as easy to visualize the wire in the vein on u/s.
 
idiot07 said:
Europeman,

I am a surgery resident. PGY-5

We put in a lot of lines. I don't know how many at this point. I would estimate >500. Who knows and who cares.

See my post about a neck hematoma not causing a problem in an intubated patient. I agree with you on that.

In an unintubated patient a neck hematoma can be a problem. Again, hasn't happened to be me, but has happened to 2 people I know who were solid residents using u/s in difficult necks. I doubt it was from vein. I suspect there was some sort unrecognized carotid stick, the lines were in the vein, The carotid wasn't dilated. No big hematoma at time of placement. Then 30 min to an hour later patient has unstable airway and dies. Even if it doesn't cause a problem you're gonna be pretty nervous for a while.

They didn't open up the neck hematoma in either case, but I think this is going to be easier said than done, as opposed to bleeding from a carotid endarectomy or thyroidectomy where you can just cut the suture line and the deep space is open. This is going to be an epic flail if the patient survives.

I think you guys are overstating the risk of an rp bleed. Again if you stick the groin in the right place the risk of rp bleed is essentially 0, you'll get a thigh or groin hematoma, and teh artery and vein are compressible. If for some reason you stick femoral artery and it bleeds into the rp that isn't that hard to control surgically, You have a small hole in the femoral arery in the groin. The rp hematoma you can't cotnrol surgically are spontaneous ones from lumbars and such. Besides they almost all stop and tamponade off as soon as coagulopathy is corrected. In the mean time the bleeding would be slow and you could keep up with transfusions...... and you're not slashing somebodies neck open at bedside. I say would and could cause, again I can't remember this happening from a cvc, I'm sure it has, but most of the time I've seen after a cardiac cath where where there was a dilator in the artery or it's spontaneous. If you want to talk about uncontrollable the perforation of the L IJ/ SCV confluence via a dilator would be much worse.

Whoever said femorals had a 3-4 higher infection rate than IJ's. That's just not true

Ann Intern Med. 2012 Nov 20;157(10):JC5-8. doi: 10.7326/0003-4819-157-10-201211200-02008.
Review: Femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections.
Whalen F.


That being said. If the patient described above had a normal iNR and didn't have hostile neck anatomy, I'd put in the IJ, but again I think a femoral line is an reasonable choice in an unintubated or squirrelly supercoagulopathic patient
Click to expand...

That is a newer paper that I was not aware of, November 2012 roughly 10 weeks old looks like, thanks for bringing it to my attention. The prior article in NEJM from 2-3 years ago showed differences in infection rates.
 
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