What is the management for bleeding during catheter insertion?

Management of Bleeding During Catheter Insertion

Firm digital pressure should be applied for at least 5 minutes at the insertion site as the primary management for bleeding during catheter insertion. 1

Initial Management of Bleeding

When bleeding occurs during catheter insertion, the following stepwise approach should be implemented:

1. Apply firm digital pressure to the insertion site for at least 5 minutes 1
2. If bleeding persists after initial compression:
   • Continue compression for additional time
   • Apply occlusive dressing after compression 1
   • Consider placement of a purse-string suture at the exit site for tunneled catheters 2

Risk Assessment and Prevention

High-Risk Factors for Bleeding

• Large-bore catheter insertion (particularly dialysis catheters) 3
• Coagulopathy (INR >1.8, aPTT >1.3 times normal, platelets <50 × 10⁹/L) 1
• Low hemoglobin levels 4
• Concurrent anticoagulation therapy 5

Preventive Measures

• Use ultrasound guidance for vessel identification and cannulation 1
• Choose catheter with smallest caliber compatible with intended therapy 1
• Position catheter tip at the superior vena cava-right atrium junction 1
• Use maximal sterile barrier precautions during insertion 1
• Consider femoral access in coagulopathic patients (despite higher infection risk) 1

Management of Severe or Persistent Bleeding

If bleeding persists despite compression:

1. Consider placement of a skin suture 1
2. For arterial puncture:
   • Small needle (21G) puncture: Remove and apply digital pressure
   • Large catheter (≥6Fr) in artery: Leave in place and consult vascular surgery/interventional radiology 1
3. For venous injury with mediastinal/pleural bleeding:
   • Leave catheter in place until vascular surgical or interventional radiology consultation 1
4. For expanding hematomas:
   • Monitor for airway compromise (especially with neck hematomas)
   • Consider surgical evacuation if causing local pressure effects 1

Special Considerations

Coagulopathic Patients

• Routine reversal of coagulopathy is only necessary if:
  • Platelet count <50 × 10⁹/L
  • aPTT >1.3 times normal
  • INR >1.8 1
• More experienced operators should perform the procedure 1
• Choose insertion sites that allow easy compression 1

Tunneled Catheters

• Consider purse-string suture at the tunnel exit site to reduce bleeding risk (reduces bleeding from 25.4% to 6%) 2
• For removal of cuffed devices, surgical cut-down may be required 1

Complications to Monitor

After managing the initial bleeding:

• Monitor for hematoma formation
• Watch for signs of hemothorax (respiratory distress, dense pleural effusion on imaging)
• Assess for airway compromise with neck hematomas
• Check for delayed bleeding after initial hemostasis

Common Pitfalls

1. Underestimating arterial puncture: Arterial puncture may not be immediately obvious; check for pulsatile flow and consider manometer tubing to differentiate venous from arterial placement 1

2. Premature catheter removal: If a catheter has penetrated a vessel wall, removing it may worsen bleeding; consult specialists before removal 1

3. Overreliance on coagulation tests: Conventional coagulation tests alone cannot reliably predict bleeding complications 3

4. Unnecessary blood product administration: Routine prophylactic correction of mild coagulopathy may have risks that exceed benefits 1

The incidence of serious bleeding complications during central line insertion is low (0.9% for grade 2 bleeding requiring prolonged compression) 3, but proper management is essential to prevent morbidity and mortality.