PACER

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Clinical Question

In patients with severe thrombocytopenia (platelets 10,000-50,000/ml3) undergoing central venous catheter placement, does platelet transfusion reduce the risk of catheter-related bleeding?

Bottom Line

Platelet transfusion in patients with severe thrombocytopenia lowered the risk of catheter-related bleeding.

Major Points

Guidelines

Design

  • Multicenter, randomized, controlled trial
  • N=338 patients; 373 catheter placements
    • Transfusion (n=188)
    • Placebo (n=185)
  • Setting: 10 hospitals in the Netherlands
  • Enrollment: February 2016 to March 2022
  • Mean follow-up:
  • Analysis: per-protocol
  • Primary outcome: grade 2 to 4 catheter-related bleeding

Population

Inclusion Criteria

  • hospitalization in an intensive care unit or hematology ward
  • platelet count 10,000 to 50,000/ml3 within 24 hours prior to the procedure
  • catheter in place for at least 24 hours

Exclusion Criteria

  • therapeutic anticoagulation
  • INR 1.5 or greater (increased to 3.0 mid-trial)
  • coagulation factor deficiency or bleeding risk

Baseline Characteristics

Characteristics are for transfusion cohort

  • Median age: 58
  • Female sex: 33.5%
  • Median platelet count: 30,000
  • Median INR: 1.1
  • Median hemoglobin: 8.2
  • Department
    • Hematology: 57.4%
    • ICU: 42.6%
  • Catheter
    • Regular: 82.4%
    • Dialysis: 17.6%
  • Tunneled catheter: 10.6%
  • Catheter site
    • Internal jugular: 49.5%
    • Subclavian: 37.8%
    • Femoral: 12.8%

Interventions

  • Randomized to one unit platelet transfusion or no transfusion prior to catheter placement
    • catheter placement by ultrasound; attempted to blind operator placing catheter
    • randomization stratified by center and catheter type

Outcomes

Comparisons are transfusion vs. no transfusion prior to catheter placement.

Primary Outcomes

Catheter-related bleeding grade 2-4
4.8% vs 11.9% (RR 2.45; 90% CI 1.27-4.70; P=0.16)

Secondary Outcomes

Grade 3-4 catheter-related bleeding
2.1% vs 4.9% (RR 2.43; 95% CI 0.75-7.93)
Death
28.2% vs. 31.7% (RR 0.94; 95% CI 0.59-1.42)
Rate of red-cell transfusion in first 24 hours
0.48 vs. 0.49 (HR 1.02; 95% CI 0.76-1.37)

Subgroup Analysis

Subgroup analyses suggested larger treatment effect with lower platelet count. There was also evidence of larger treatment effect for patients with subclavian catheters compared to internal jugular, hematology patients compared to intensive care unit, and nontunneled compared to tunneled.

Adverse Events

Allergic transfusion reaction
1.0% vs 0.5% (RR 0.50; 95% CI 0.05-5.51)
Acute lung injury
0.5% vs 0% (0.50; 95% CI 0.05-5.48

Criticisms

Funding

  • Supported by ZonMw, part of the Dutch Research Council.

Further Reading