Paracentesis and Coagulopathies

Author: Dr. Ethan Szpara

Edited by: Kevin Cao

Clinical Question

Diagnostic paracentesis is a common procedure that takes place in the Emergency Department. I found that while working at UIC I noted an increased prevalence of coagulopathies in patients with liver disease.

I questioned how this might affect our approach to procedures being performed on these patient’s such as diagnostic paracentesis. One of our chief’s recommended that I look at this study to address this question.

Article of Interest

Rowley M.W, Agarwal S, Seetharam A, Hirsch K.S. Real-Time Ultrasound-Guided paracentesis by Radiologists: Near Zero Risk of Hemorrhage without Correction of Coagulopathy. Journal of Vascular and Interventional Radiology. 2019; 30, 2: 259-264

Study Design

This was a retrospective study that included all patients from a large liver transplant center that underwent diagnostic and therapeutic paracentesis over a two-year period. Patient data was obtained through an extensive review of this institutions EMR. The purpose was to evaluate the rate of hemorrhage in patient undergoing real-time, US guided paracentesis without any correction of coagulopathy.

Results

Patients that received paracentesis without correction of coagulopathy had a bleeding risk of 0.19%. In total 6 patients of the 3,116 patients required post-paracentesis pRBC transfusion. No patients died from paracentesis related complications.

Conclusion

Patients that have coagulopathy due to liver disease have a very low bleeding risk following paracentesis when being performed under ultrasound guidance.
Rebalanced homeostasis explains that patients with liver disease are deficient in both pro-coagulant, and anti-coagulant proteins in a way so that their coagulation status is “rebalanced.”
INR is a poor indicator of homeostasis in patients with liver disease as described by the concept of rebalanced homeostasis such as that a patient may have an elevated INR but may have an overall greater deficiency in anti-coagulant proteins, and therefore can have an increased risk of clotting.
Following a cost savings analysis, the practice of not correcting for coagulopathy in patients with liver disease prior to paracentesis leads to significant hospital savings.

Application:

I will not correct for coagulopathy in patients with liver disease prior to diagnostic paracentesis in the ED unless otherwise indicated by severe lab derangements.

References

Pache I, Bilodeau M. Severe hemorrhage following abdominal para-centesis for ascites in patients with liver failure. Aliment Pharmacol Ther 2005; 21:525–529.

Northup P.G, Caldwell S.H. Coagulation in Liver Disease: A Guide for the Clinician. Clinical Gastroenterology and Hepatology. 2013;11, 9: 1064-1074.

Giannini E.G, Greco A, Marenco S, Andorno E, Valente U, Savarino V. Clinical Gastroenterology and Hepatology, 2010; 8,10. 899-902.