Prophylactic platelet transfusion lowers bleeding risk before CVC placement among severe thrombocytopenia patients: NEJM

In this randomized, controlled trial, the noninferiority of withholding transfusion was not shown for the primary outcome of grade 2 to 4 bleeding. Other secondary outcomes, such as grade 1 bleeding, grade 3 or 4 bleeding, and hematoma occurrence, consistently suggested that bleeding risk was higher in the no-transfusion group. In contrast, the number of transfusion reactions was low.

CVC placement is a frequently performed invasive procedure that allows for administering vasoactive drugs, simultaneous infusion of multiple medications, irritating or hypertonic solutions, and hemodynamic and hemodialysis monitoring. About 18% of hospitalized patients undergo CVC placement, which is higher in the ICU (intensive care unit) or haematology ward, where patients also frequently have thrombocytopenia.

Transfusion guidelines on platelet-count thresholds before placing a central venous catheter (CVC) offer conflicting recommendations owing to a lack of good-quality evidence. The routine use of ultrasound guidance has reduced CVC-related bleeding complications.

Alexander P.J. Vlaar and colleagues from the Netherlands conducted a multicenter, randomized, controlled, noninferiority trial. Patients with severe thrombocytopenia (platelet count, 10,000 to 50,000 per cubic millimetre) who were being treated on the haematology ward or in the ICU were randomly assigned to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement.

The study's primary outcome was catheter-related bleeding of grade 2 to 4; grade 3 or 4 bleeding was a key secondary outcome. The noninferiority margin was an upper boundary of the 90% confidence interval of 3.5 for the relative risk.

The authors reported the following findings:

• Three hundred seventy-three episodes of CVC placement involving 338 patients in the per-protocol primary analysis were included.
• Catheter-related bleeding of grade 2 to 4 occurred in 4.8% of patients in the transfusion group and 11.9% in the no-transfusion group (relative risk, 2.45).
• Catheter-related bleeding of grade 3 or 4 occurred in 2.1% of patients in the transfusion group and 4.9% in the no-transfusion group (relative risk, 2.43).
• A total of 15 adverse events were observed; 13 (all grade 3 catheter-related bleeding [4 in the transfusion group and 9 in the no-transfusion group]) were categorized as severe.
• The net savings of withholding prophylactic platelet transfusion before CVC placement was $410 per catheter placement.

"In patients with severe thrombocytopenia, we found that withholding prophylactic platelet transfusion before CVC placement in those with a platelet count of 10,000 to 50,000 per cubic millimetre did not meet the predefined margin for noninferiority and resulted in more CVC-related bleeding than prophylactic platelet transfusion," the researchers concluded.

Reference:

The study, "Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia," was published in the New England Journal of Medicine. DOI: 10.1056/NEJMoa2214322