Procedures in patients with coagulopathies

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)
  • 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

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. 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.
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