CVK vid defekt hemostas. Fredrik Öberg Bitr överläkare Anestesikliniken Karolinska Solna

Transkript

1 CVK vid defekt hemostas Fredrik Öberg Bitr överläkare Anestesikliniken Karolinska Solna

2 SFAI riktlinjer

3 Vad är man rädd för? Stor blödning med fatal utgång Sällsynt Svårt att studera Koagulopati? Andra faktorer? Sivande blödning Hematom 3

4 KS 2013 Kärlet identifieras ua med ultraljud Punktion ua, ultraljudslett, skarp nål, venöst backflöde J-ledaren ner i kärlet ua, dock lite mer motstånd än normalt Koll med rtg-genomlysning, J-ledaren ser ut att ligga rätt Hudstick + tunnelering av slang ua (med ledaren på plats) Dilatator + hylsa träs ner över ledaren Klart mer motstånd än normalt, fick ta i lite Pat klagar på att det känns konstigt att andas Dilatator ut (hylsan kvar) 4

5 KS 2013 Oklart om blodretur via hylsan, fingret på direkt Bums ner med katetern genom hylsan Kunde ej flusha eller aspirera Kallade på hjälp Tittade, kollade med rtg-genomlysning, katetern såg ut att ligga rätt Drog långsamt ut slang och aspirerade samtidigt ingen retur Till slut kom hela slangen ut Beslut stick om! 5

6 KS 2013 Pat klagar på att det känns konstigt att andas Pat blir tachykard Hmm nån konstig arytmi eller.? Går runt och kollar patienten Pat likblek, blir medvetslös trycker på larmknappen HLR 6

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14 Danmark

15 Danmark 15

16 USA

17 USA 103 fall wire/catheter embolus (n 20), cardiac tamponade (n 16), carotid artery puncture/cannulation (n 16), hemothorax (n 15), and pneumothorax (n 14) Nearly half of the central catheter claims were judged as possibly preventable by either ultrasound guidance or pressure waveform Coagulopathy? 17

18 Sverige Anders Larsson, Gävle, opubl data Lex Maria-, HSAN- och Patientskadeärenden 10 dödsfall Allvarliga brister i teknik och handläggning I ett ärende diskuteras hemostasdefekt som möjlig bidragande orsak 18

19 SFAI riktlinjer

20 SFAI riktlinjer artiklar 100 intressanta abstracts 54 granskade artiklar Sedan dess: Ytterligare 10 20

21 N (nr of Study design and Catheter type and Ultrasound SFAI riktlinjer 2011 catheters) Setting cannulation site used Ref nr Publ year Purpose and/or methods Outcome Comment Weigand K et al. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters Open prospective, Dialysis Yes - Two groups, with cutoff at PLT=50 nonrandomized. Std 3-lumen and/or INR=1,5. 2xICU IJV 88% - Analysed for bleeding, measured as 1XHemathology HDU SCV 10% Hb-drop > 1,5 g/dl post CVC insertion. FV 2% Lee AC. Elective removal of cuffed central venous catheters in children N/A Literature study Tunneled catheters N/A Study of complications from removal of cuffed lines, both adults and children. Recommendations stated for children. Stecker MS et al. Time to hemostasis after traction removal of tunneled cuffed central venous catheters Open? Prospective nonrandomized Cuffed tunneled cvc, jugular or femoral. Tercan F et al. US-guided placement of central vein catheters in patients with disorders of hemostasis Open Prospective, case series Yes - IJV 97% - 18 G needle - 12F (n=106), 7F (n=21), 6F (n=6) Lozano M et al. Platelet transfusion in thrombotic thrombocytopenic purpura: between Scylla and Charybdis Two case series TTP Patients Not stated Plasma exchange catheters, mostly subclavian route N/A To study correlation between abnormal coag studies (PT, INR, APTT, PLT) and time to hemostasis after traction removal. To study the frequency of bleeding (=oozing and/or hematoma) in a group of patients having PLT 50 and/or INR 1,5 and/or APTT 50s. Paper refers to two case studies of patients with TTP, total of 149 patients - 58 of 196 pat had coagulopathy - No difference between groups - 34 pats (17,4%) had Hbdrop > 1,5, 7 of which in coagulopathy group - No major bleeding (i.e. other than oozinghematoma). Air embolism most common complication. No bleeding of 179 pat had PLT<50 and/or INR> No correlation between coag studies and time to hemostasis. -End stage renal failure, antiplatelet agents, and low-volume operator correlated with prolonged time to hemostasis. -92% had hemostasis within 5 min. Only one patient took more than 15 min. - No major bleeding. - 3,8% oozing, 1,5% hematoma, 0,8% both. - Mean PLT=30.6, INR=3.1, APTT=70s Two deaths from hemorrhage, both subclavian punctures, unclear if ultrasound - Quite a lot of bleeding in this study! - Hb-drop > 1,5 is a rather crude measure of oozing/haematoma. - None of those with both PLT<50 and INR>1,5 had a Hb-drop. This suggests choice of safer technique and/or experienced operator for those with the most severe coagulopathy Interesting - Pats with severely abnormal coag was excluded (APTT>100s, INR>4, PLT<10, heparin infusion) - Unclear whether patient characteristics were known by operators (choice of techniquie/operator affected by pat characteristics?) - Presumably all these catheters had been there for quite a while, therefore no conclusions can be drawn about removal of newly put in catheters (i.e. those without a fibrin sheath around them). - No arterial punctures in entire series - 100% success rate. - Mean no of attempts 1,01. - Very experienced operators, all lines placed by only two radiologists with 8 and 5 years of experience on US-guided CVC placement - Bad choice of technique and puncture site for coagulopathic patients? Author had no data on the use of ultrasound ( correspondence) Neunert CE et al. Implantable central venous access device procedures in haemophilia patients without an inhibitor: systematic review of the literature and institutional experience N/A Review CVC and ports Not stated General guidelines on CVC and ports in hemophiliacs Always give factor concentrates prior to insertion if possible Segal JB, Dzik WH; Transfusion Medicine/Hemostasis Clinical Trials Network. Paucity of studies to support that abnormal coagulation test results predictbleeding in the setting of invasive procedures: an evidence-based review N/A Literature study Various invasive Not stated Is pathologic INR / PT predictive of There is not sufficient Covers bronchoscopy, CVC, Femoral angiography, liver biopsy or 21

22 INR (leversvikt) 22

23 leversvikt 658 kanyleringar INR 1 17 TPK artärpunktioner En hemothorax efter artärstick i subclavia (TPK 68) Cutoff för sivande blödn / hematom TPK<50 INR > 5 internal jugular cannulation, more than one needle pass into the vein, failure to pass any guidewire, high INR, low platelets, heparin therapy 23

24 Heparin

25 heparin 516 kanyleringar 252 fullhepariniserade 22 artärpunktioner 22 hematom 13 med heparin 9 utan heparin av 22 artärpunktioner 12 med heparin, 10 utan 7 hematom 4 med heparin, 3 utan 25

26 TPK 26

27 TPK 133 kanyleringar TPK (medel 30.6) 100 % success rate Inga artärpunktioner No major bleeding 8 oozing / hematoma / both 2 (glada) interventionister 27

28 Etc 28

29 Etc Invasive linte placement in critically ill patients: Do hemostatic defects matter? Should plasma be transfused prophylactically before invasive procedures etc : Bleeding complications of central venous catheterization in septic patients with abnormal hemostasis. 29

30 Sammanfattning Stor blödning Endast vid allvarlig brist i teknik och handläggning Inga stora blödningar pga koagulopati vid korrekt handläggning Hemostasdefekt kan bidra (?) Sivande blödning / hematom Dålig korrelation med labprover Kombinationer (läkemedel, övriga faktorer) 30

31 Praktiska råd Anamnes Prover aldrig rutinmässigt 31

32 Praktiska råd Optimera sällan Aldrig rutinmässigt Tänk på hela patienten (och mindre på anestesiologen) Vid misstänkt hemostasdefekt: Erfaren operatör Säker teknik Avbryt eller ändra strategi vid problem Övervakning post op Tunnelerade katetrar och venportar Korrigera vid behov (och om möjligt) som vid medelstor kirurgi (APTT 1.3 x ref, TPK 50, INR 1.8, ) 32

33 Praktiska råd Friläggning är inte visat bättre än stick Tänk på patienten och inte på anestesiologen 33