Procedures in patients with coagulopathies: Difference between revisions

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==Background==
*All of the below rules are guidelines with mostly retrospective and case report evidence.  All rules need to account for operator experience. The most experienced operator should perform the procedure.
*All of the below rules are guidelines with mostly retrospective and case report evidence.  All rules need to account for operator experience. The most experienced operator should perform the procedure.


==Paracentesis==
==[[Paracentesis]]==
*Coagulation studies are NOT required before performance of the procedure<ref>Wilkerson, Annals of Emerg Med, 2009</ref>
*Coagulation studies are NOT required before performance of the procedure<ref>Wilkerson, Annals of Emerg Med, 2009</ref>
*No data supports cutoff values beyond which paracent should be avoided/prophylactically transfused
*No data supports cutoff values beyond which paracent should be avoided/prophylactically transfused
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*Contraindicated if the patient is actively bleeding or in [[DIC]] and the incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)<ref>Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21</ref>
*Contraindicated if the patient is actively bleeding or in [[DIC]] and the incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)<ref>Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21</ref>


==Thoracentesis==
==[[Thoracentesis]]==
*Consider transfusion of platelets if platelets <50,000, or Fresh Frozen Plasma if PT/PTT twice the normal range <ref>McVay P. et al. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71</ref>
*Consider transfusion of platelets if platelets <50,000, or Fresh Frozen Plasma if PT/PTT twice the normal range <ref>McVay P. et al. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71</ref>


==Lumbar Puncture==
==[[Lumbar Puncture]]==
*Tranfuse if platelets <25,000<ref>Howard SC, Gajjar A, Ribeiro RC, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222–2224</ref><ref>Vavricka SR, Walter RB, Irani S, Halter J, Schanz U. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 2003; 82:570–573</ref>
*Tranfuse if platelets <25,000<ref>Howard SC, Gajjar A, Ribeiro RC, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222–2224</ref><ref>Vavricka SR, Walter RB, Irani S, Halter J, Schanz U. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 2003; 82:570–573</ref>
*If hemophiliac, replace factor before LP
*If hemophiliac, replace factor before LP


==Central Line==
==[[Central Line]]==
*If coagulopathic, use a compressible site such as the femoral location (avoid the IJ and Subclavian if possible)
*No benefit FFP unless you lacerate an artery<ref>Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5</ref>
*No benefit FFP unless you lacerate an artery<ref>Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5</ref>
*However, consider if patient is a [[Hemophilia|hemophilia]]<ref>Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemo- philia 2001; 7:551–556</ref>
**However, consider if patient has [[Hemophilia|hemophilia]]<ref>Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556</ref>
*Favor using a compressible site such as the femoral location if coagulopathic and avoid the IJ and Subclavian


==See Also==
==See Also==

Revision as of 20:13, 3 July 2014

Background

  • All of the below rules are guidelines with mostly retrospective and case report evidence. All rules need to account for operator experience. The most experienced operator should perform the procedure.

Paracentesis

  • Coagulation studies are NOT required before performance of the procedure[1]
  • No data supports cutoff values beyond which paracent should be avoided/prophylactically transfused
  • Routine use of FFP and platelets is not recommended
  • Contraindicated if the patient is actively bleeding or in DIC and the incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)[2]

Thoracentesis

  • Consider transfusion of platelets if platelets <50,000, or Fresh Frozen Plasma if PT/PTT twice the normal range [3]

Lumbar Puncture

  • Tranfuse if platelets <25,000[4][5]
  • If hemophiliac, replace factor before LP

Central Line

  • If coagulopathic, use a compressible site such as the femoral location (avoid the IJ and Subclavian if possible)
  • No benefit FFP unless you lacerate an artery[6]

See Also

Further Reading

  • Indravadan P. et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. J Vasc Interv Radiol 2012 PDF

Sources

  • Roberts, Clin Proc Emer Med 2004; Yu (Clin Liv Dz '01)
  1. ↑ Wilkerson, Annals of Emerg Med, 2009
  2. ↑ Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21
  3. ↑ McVay P. et al. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71
  4. ↑ Howard SC, Gajjar A, Ribeiro RC, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222–2224
  5. ↑ Vavricka SR, Walter RB, Irani S, Halter J, Schanz U. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 2003; 82:570–573
  6. ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  7. ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
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