Procedures in patients with coagulopathies: Difference between revisions
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== | ==Background== | ||
* | *Evidence is mostly retrospective studies or case reports | ||
* | *Clinical practice should account for totality of circumstances, including operator experience | ||
== | ==[[Central line|Central Line]]== | ||
{{Central line with coagulopathy}} | |||
==Lumbar Puncture== | ==[[Lumbar Puncture]]== | ||
{{Lumbar puncture with coagulopathy}} | |||
== | ==[[Paracentesis]]== | ||
{{Paracentesis if coagulopathic}} | |||
* | |||
==[[Thoracentesis]]== | |||
{{Thoracentesis with coagulopathy}} | |||
==Specific Populations== | |||
===Cirrhosis<ref>Caldwell SH. Management of Coagulopathy in Liver Disease. Gastroenterol Hepatol (N Y). 2014 May; 10(5): 330–332.</ref>=== | |||
*INR is a poor marker of coagulation in [[cirrhosis]] | |||
*Risk of post-procedure bleeding for minimally invasive procedures ~20% in cirrhotics | |||
*Each 100 cc infusion of plasma increases portal venous pressure by 1 mmHg (normal pressure 5-10 mmHg) | |||
*Correction of elevated INR in [[cirrhosis]] leads to unnecessary volume expansion | |||
**PT/INR only measures the procoagulant pathway and does not detect anticoagulant pathway (protein C and S, antithrombin) | |||
**Thus, cirrhotic patients may be hypercoagulable despite high INR due to natural anticoagulant deficiencies<ref>Brea Lipe and Deborah L. Ornstein. Deficiencies of Natural Anticoagulants, Protein C, Protein S, and Antithrombin. Published: October 4, 2011. Circulation. http://circ.ahajournals.org/content/124/14/e365.</ref> | |||
**Do not use PT/INR to risk stratify liver disease patients | |||
**Rather use target platelet count with goal > 50,000 uL and fibrinogen level > 120 mg/dL | |||
==See Also== | ==See Also== | ||
*[[Coagulopathy (Main)]] | *[[Coagulopathy (Main)]] | ||
== | ==External Links== | ||
* | *http://www.sirweb.org/clinical/cpg/4E8CAd01.pdf | ||
==References== | |||
<references/> | |||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Heme/Onc]] | [[Category:Heme/Onc]] |
Latest revision as of 05:50, 7 July 2017
Background
- Evidence is mostly retrospective studies or case reports
- Clinical practice should account for totality of circumstances, including operator experience
Central Line
Central line if coagulopathic
- Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible, though IJ preferred over subclavian)
- No benefit to giving FFP unless artery is punctured[1]
- However, consider giving FFP if patient has hemophilia[2]
Lumbar Puncture
Lumbar puncture if coagulopathic
- Tranfuse if platelets <25,000[3][4]
- INR >1.5
- Hemophilia, von Willebrand disease, other coagulopathies
- If hemophiliac, replace factor before LP
Paracentesis
Paracentesis if coagulopathic
- Coagulation studies are NOT required before performance of the procedure[5]
- Incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)[6]
- No data supports cutoff values beyond which paracentesis should be avoided/prophylactically transfused
- Routine use of FFP and platelets is not recommended
- Procedure is contraindicated if the patient is actively bleeding or in DIC
Thoracentesis
Thoracentesis if coagulopathic
Specific Populations
Cirrhosis[8]
- INR is a poor marker of coagulation in cirrhosis
- Risk of post-procedure bleeding for minimally invasive procedures ~20% in cirrhotics
- Each 100 cc infusion of plasma increases portal venous pressure by 1 mmHg (normal pressure 5-10 mmHg)
- Correction of elevated INR in cirrhosis leads to unnecessary volume expansion
- PT/INR only measures the procoagulant pathway and does not detect anticoagulant pathway (protein C and S, antithrombin)
- Thus, cirrhotic patients may be hypercoagulable despite high INR due to natural anticoagulant deficiencies[9]
- Do not use PT/INR to risk stratify liver disease patients
- Rather use target platelet count with goal > 50,000 uL and fibrinogen level > 120 mg/dL
See Also
External Links
References
- ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
- ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
- ↑ 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
- ↑ 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
- ↑ Wilkerson, Annals of Emerg Med, 2009
- ↑ Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21
- ↑ 7.0 7.1 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
- ↑ Caldwell SH. Management of Coagulopathy in Liver Disease. Gastroenterol Hepatol (N Y). 2014 May; 10(5): 330–332.
- ↑ Brea Lipe and Deborah L. Ornstein. Deficiencies of Natural Anticoagulants, Protein C, Protein S, and Antithrombin. Published: October 4, 2011. Circulation. http://circ.ahajournals.org/content/124/14/e365.