Discussion
Hematopoetic stem cell transplantation (HCT) is generally associated
with variable periods of severe thrombocytopenia. However, major
bleeding (defined as any bleeding other than petechiae or mucosal)
occurs in a minority of patients and it is unclear if the administration
of platelets is required for central venous catheter removal .
All patients had time to hemostasis within 5 minutes of catheter
removal. Our findings were similar to those observed by Stecker et
al7. While removing the CVL we did not make an extra
effort to remove the polyester cuff if it separated from the catheter as
this has been shown to be of no clinical significance in most
patients8. Moreover, in our subset of patients,
primarily with non-malignant diseases, the tunnelled CVL was inserted at
the time of conditioning start, so that little or no cuff fibrosis was
present at the time of removal. One concern may be the achievement of
hemostasis if traction removal fails in a particular patient and a cut
down is required to remove the catheter. Unlike the study by
Stecker7, none of our patients developed this
complication. Interestingly, only about five minutes of manual
compression were needed to attain complete hemostasis.
Although Stecker et al7 in their study reported
adverse events like bruising, minimal blood oozing and discomfort, which
are not uncommonly seen, none of our subjects reported any of these
events.
Bedside removal of CVL under local anaesthesia remained
complication-free even at platelets counts less than 20,000/uL.
In total, 17 lines were pulled out without any complications when
platelets were below 5,000 with only RDP transfusions support.
Hemoglobin drop of more than 1 gm/dL was observed in 5 of the patients
but none showed any signs of overt bleeding and did not require any PRBC
transfusion post CVL removal.
None of our patients, irrespective of place of removal of CVL, showed
any complications.
Of the 31 patients who had fever at the time of CVL removal, 17 (54.8%)
became afebrile within 2 days of removal.
Positive CVL cultures were reported in 16 patients of whom 1 died
(6.25%). A study by Rodriguez et al reported a mortality of
31%8.
A total of 18 patients had elevated CRP levels at the time of CVL
removal, of these only 3 showed a decrease in values in the next two
days.
Five patients had raised PCT levels at the time of CVL removal, 2 showed
decreased PCT levels in the following two days. Even if the mortality
associated with CVL infections is still a subject of methodological
debates9,10, morbidity is well documented and includes
severe sepsis and septic shock, septic thrombophlebitis, endocarditis
and thromboembolism11.
Neutropenia is a major independent risk factor for CRIs, and neutropenic
patients with bloodstream infections are at higher risk of mortality
compared with non-neutropenic patients12. In our cases
defervescence and septic markers response seemed to be independent of
concomitant neutrophil recovery.
Although patients undergoing allogeneic or autologous HCT are commonly
neutropenic, transplantation might further increase the risk of CVL
infections independent of the impact of neutropenia. In a recent
retrospective study by McDonald and colleagues, on 352 patients
undergoing allogeneic HCT, the use of a matched unrelated donor (MUD)
and/or haploidentical donor and the use of an ablative conditioning
regimen were independently associated with development of CVL infections
on multivariate analysis13.
The emergence of MDR germs is a growing threat14 so
any measure limiting the prolonged use of high-end antibiotics is
particularly relevant.
In view of increased threat of developing multi drug resistant
microorganisms, CVL removal becomes a necessity to reduce morbidity and
eventually mortality in patients in ICU settings and patients undergoing
HCT.
Placement of tunnelled central venous catheters has been extensively
studied, but we were not able to find any reports on removal-related
complications during severe pancytopenia or on the impact of PT, INR,
aPTT or platelets transfusions before traction catheter removal.
In conclusion, though our study has limitations in its sample size, it
suggests that central lines can be safely removed with platelet counts
less than 20,000/ul and that this may result in enhanced blood stream
infection control. This might be particularly relevant to neutropenic
patients in this day and age of MDR germs emergence and paucity of new
effective antibiotics. In our opinion, the risk of infection progression
leaving an indwelling CVL in pancytopenic patients with persistent fever
not responding to broad spectrum antibiotics far outweigh the minimal
risk of severe bleeding associated with CVL removal during severe
thrombocytopenia.
Conflict of Interest statement: We declare no conflicts of
interest.
Acknowledgements: We would like to thank all our patients and
their families. We would also like to thank all the institutions who
were involved in caregiving.