REVIEW QUESTION

Are prophylactic plasma transfusions safe and effective prior to placement of a central venous catheter (CVC) in people with abnormal coagulation?

TYPE OF REVIEW

This is a systematic review of one randomized controlled trial (RCT) of 58 adults with abnormal coagulation requiring placement of a CVC.

RELEVANCE FOR NURSING

Approximately 8% of patients require placement of a CVC during hospitalization. People requiring a CVC often have complex medical conditions or emergent declines in health status. Coagulopathy, either from chronic disease or acute illness, is a common finding in these patients.

Current management for people with coagulopathy requiring a CVC varies among facilities and is largely based on expert opinion. The goal is to prevent significant bleeding in the postprocedure period. One of the more common methodologies includes prophylactic plasma transfusions prior to insertion of the central line. Plasma transfusions, however, are not without potential complications, including transfusion reactions, transfusion-transmitted infection, and damage to the lungs and circulatory system. An evidence-based clinical guideline for the management of coagulopathy in people requiring CVC placement is crucial to ensuring safe, effective nursing care.

CHARACTERISTICS OF THE EVIDENCE

Only one RCT was available for inclusion in this review. The study population included patients older than 18 years admitted to the ICU with an international normalized ratio (INR) of 1.5 to 3, who had abnormal coagulation profiles requiring the placement of a CVC. The study compared a plasma transfusion (one 12 mL/kg dose of fresh frozen plasma [FFP]) prior to insertion of the CVC with no plasma transfusion prior to insertion.

The primary outcomes were major postprocedure bleeding within the first 24 hours after CVC insertion and 30-day postprocedure all-cause mortality. There were numerous secondary outcomes of interest including minor bleeding 24 hours after the procedure and transfusion-related complications within 24 hours of the procedure.

There was no evidence of major postprocedure bleeding in either the intervention (FFP) or comparison (no FFP) group; 30-day all-cause mortality was not reported in this study. There was insufficient evidence to evaluate the incidence of minor postprocedure bleeding within the first 24 hours. The intervention group had only two episodes of minor bleeding, while the comparison group had three episodes. Transfusion-related complications were not reported in the study. The evidence was determined to be of very low quality.

BEST PRACTICE RECOMMENDATIONS

Because there was no evidence of major postprocedure bleeding in either the intervention or the comparison group, no conclusion can be drawn related to the necessity or efficacy of plasma transfusions prior to the insertion of CVCs in people with coagulopathy and abnormal INR values.

RESEARCH RECOMMENDATIONS

There is a lack of research on the management of coagulopathy in people requiring CVC placement. This systematic review focused only on one dose of plasma and only on adults. Future research should evaluate the safety and efficacy of plasma transfusions in other age groups. If further investigation reveals that plasma transfusion prior to central line insertion in people with abnormal coagulation is effective, additional research will be needed to determine the best dose to produce the desired effect. Large-scale clinical trials are also needed to produce evidence to drive accurate clinical guidelines related to the management of coagulopathy in the presence of CVC placement.

REFERENCE