Procedures in patients with coagulopathies: Difference between revisions
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==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 supporting cutoff values for coags/platelets beyond which paracent should be avoided/prophylactically transfused
*No data supports cutoff values beyond which paracent should be avoided/prophylactically transfused
**routine use of FFP and platelets is not recommended
*Routine use of FFP and platelets is not recommended  
*contraindicated only if DIC or fibrinolysis
*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>
*incidence of clinically significant bleeding complications low even in liver failure (< 0.2%)
*Greatly increased serum creatinine levels --> consider post-procedure observation


==Thoracentesis==
==Thoracentesis==
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==Lumbar Puncture==
==Lumbar Puncture==
*Tranfuse if platelets <50,000<ref>Roberts, Clin Proc Emer Med 2004</ref><ref>Johnson KS, et al. Lumbar puncture: Technique, indications, contradindications, and complications in adults. Sept 18, 2013. UpToDate.</ref> or INR >1.4<ref>Johnson KS, et al. Lumbar puncture: Technique, indications, contradindications, and complications in adults. Sept 18, 2013. UpToDate.</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==
*No benefit FFP if artery isn't hit<ref>Am J Surg '01</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>
*Consider transfuse if plat <50,000
*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>
*Use compressible site if coagulopathic (jury is still out)
*Favor using a compressible site such as the femoral location if coagulopathic and avoid the IJ and Subclavian


==See Also==
==See Also==
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==Sources==
==Sources==
*Kaji Questions, Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21.
*Indravadan P. et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions [http://www.sirweb.org/clinical/cpg/4E8CAd01.pdf PDF]
*Roberts, Clin Proc Emer Med 2004; Yu (Clin Liv Dz '01)
*Roberts, Clin Proc Emer Med 2004; Yu (Clin Liv Dz '01)
  <references/>
  <references/>

Revision as of 14:54, 3 July 2014

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

  • No benefit FFP unless you lacerate an artery[6]
  • However, consider if patient is a hemophilia[7]
  • Favor using a compressible site such as the femoral location if coagulopathic and avoid the IJ and Subclavian

See Also

Sources

  • Indravadan P. et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions PDF
  • 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. Haemo- philia 2001; 7:551–556
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