Procedures in patients with coagulopathies: Difference between revisions

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==Paracentesis==
==Background==
*Coagulation studies are NOT required before performance of the procedure<ref>Wilkerson, Annals of Emerg Med, 2009</ref>
*Evidence is mostly retrospective studies or case reports
**no data supporting cutoff values for coags/platelets beyond which paracent should be avoided/prophylactically transfused
*Clinical practice should account for totality of circumstances, including operator experience
**routine use of FFP and platelets is not recommended
*contraindicated only if DIC or fibrinolysis
*incidence of clinically significant bleeding complications low even in liver failure (< 0.2%)
*Greatly increased serum creatinine levels --> consider post-procedure observation


==Thoracentesis==
==[[Central line|Central Line]]==
*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>
{{Central line with coagulopathy}}


==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>
{{Lumbar puncture with coagulopathy}}
*If hemophiliac, replace factor before LP


==Central Line==
==[[Paracentesis]]==
*No benefit FFP if artery isn't hit<ref>Am J Surg '01</ref>
{{Paracentesis if coagulopathic}}
*Consider transfuse if plat <50,000
 
*Use compressible site if coagulopathic (jury is still out)
==[[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)]]


==Sources==
==External Links==
*Paracentesis: Kaji Questions, Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21.
*http://www.sirweb.org/clinical/cpg/4E8CAd01.pdf
*Roberts, Clin Proc Emer Med 2004; Yu (Clin Liv Dz '01)
 
<references/>
==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]

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

  • Platelets <50K[7]
  • INR >2x normal[7]
  • Mechanical ventilation

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

  1. Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  2. Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
  3. 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
  4. 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
  5. Wilkerson, Annals of Emerg Med, 2009
  6. Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21
  7. 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
  8. Caldwell SH. Management of Coagulopathy in Liver Disease. Gastroenterol Hepatol (N Y). 2014 May; 10(5): 330–332.
  9. 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.