Central venous cannulation in patients with liver disease and coagulopathy - a prospective audit

Objective:To determine the incidence of vascular complications associated with central venous cannulation in patients with liver disease and coagulopathy. Design: A prospective audit of all cannulation episodes in patients with liver disease and a prothrombin (INR) more than 1.5 and/or platelet count of 150 x 10(9)/l or less. Setting: A specialist liver unit between January 1996 and September 1997. Patients: Patients with acute or chronic liver diseases and patients undergoing liver transplantation or other hepatobiliary surgery. Measurements and results: Vascular complications of central venous cannulation were classified as major (any haemodynamically significant haemorrhage) or minor (superficial oozing or haematoma). We recorded 658 cannulations (subclavian, 352, and internal jugular, 306). The median INR was 2.4 (range 1-16) in the subclavian group and 2.7 (1-17) in the internal jugular group (p < 0.05); median platelet counts were 81 x 10(9)/l (range 9-1088) and 83 x 10(9)/l (10-425), respectively (difference not significant). One patient developed a haemothorax after accidental subclavian artery puncture (INR was 1.5, platelets 68 and regional prostacyclin therapy was being given or haemofiltration). There were no other major vascular complications. Risk factors for minor vascular complications included internal jugular cannulation, more than one needle pass into the vein, failure to pass any guidewire, a high INR and low platelets for haematoma formation, and low platelets and heparin therapy for superficial oozing. Conclusions: The incidence of major vascular complications following central venous cannulation in patients with liver disease and coagulopathy was low in this audit. In liver disease the presence of a raised INR alone should not be considered a contra-indication to central venous cannulation.