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.