Procedures in patients with coagulopathies

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  • 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

  • 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

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. Haemo- philia 2001; 7:551–556
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