title: Bleeding complications of central venous catheterization in septic patients with abnormal hemostasis.
abstract: OBJECTIVE
  Central venous catheterization (CVC) is thought to be relatively contraindicated in patients with thrombocytopenia or coagulopathy. We measured the 24-hour incidence of bleeding in septic emergency department (ED) patients undergoing CVC.
  
  
  METHODS
  This multicenter, retrospective cohort study included septic ED patients undergoing CVC with one of the following: platelets less than 100,000/μL, international normalized ratio at least 1.3, or partial thromboplastin time at least 35 seconds. Major bleeding included radiographically confirmed intrathoracic, mediastinal, or internal neck hemorrhage or line-related bleeding causing hemodynamic compromise. Minor bleeding included local oozing or superficial hematoma. Multivariable regression analysis was performed to determine the association between candidate variables and hemorrhagic complications.
  
  
  RESULTS
  Of the 936 cases, mean age was 68.1 years; 535 (57.2%) were male. Two or more qualifying laboratory abnormalities were present in 204 cases (21.8%). The proceduralists were predominately attendings (790; 84.4%). The initial veins were the internal jugular (n = 800; 85.5%), subclavian (n = 123; 13.1%), and femoral (n = 13; 1.4%). Initial access was successful in 872 cases (93.2%). We found one case (95% upper confidence limit: 0.6%) of major bleeding and 37 cases (4.0%; 95% confidence interval [CI], 2.8%-5.4%) of minor bleeding. Only failed access at the initial site was independently associated with hemorrhagic outcomes: adjusted odds ratio 8.2 (95% CI, 3.7-18.0).
  
  
  CONCLUSIONS
  Major bleeding from CVC in ED patients with abnormal hemostasis is rare. Minor bleeding is uncommon and infrequently requires intervention. Successful catheterization on the initial attempt is associated with fewer hemorrhagic complications. These results can inform the risk/benefit calculus for CVC in this population.
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente Roseville Medical Center, Roseville, CA. Electronic address: drvinson@ucdavis.edu.
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente San Rafael Medical Center, San Rafael, CA.
authors.forename: Dustin W
authors.initials: DW
authors.lastname: Ballard
authors.affiliation: California State University, Sacramento, CA.
authors.forename: Luke G
authors.initials: LG
authors.lastname: Hance
authors.affiliation: Kaiser Permanente Division of Research, Oakland, CA.
authors.forename: YunYi
authors.initials: Y
authors.lastname: Hung
authors.affiliation: Kaiser Permanente Division of Research, Oakland, CA.
authors.forename: Adina S
authors.initials: AS
authors.lastname: Rauchwerger
authors.affiliation: Kaiser Permanente Division of Research, Oakland, CA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Reed
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente Hayward Medical Center, Hayward, CA.
authors.forename: Mamata V
authors.initials: MV
authors.lastname: Kene
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA.
authors.forename: Uli K
authors.initials: UK
authors.lastname: Chettipally
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente South Sacramento Medical Center, Sacramento, CA.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Elms
authors.affiliation: The Permanente Medical Group, Oakland, CA; Kaiser Permanente Oakland Medical Center, Oakland, CA.
authors.forename: Dustin G
authors.initials: DG
authors.lastname: Mark
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000150:complications*; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D018805:Sepsis / Q000150:complications*; D013921:Thrombocytopenia / Q000150:complications*