Paracentesis and Coagulopathies
Author: Dr. Ethan Szpara
Edited by: Kevin Cao
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
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.
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.
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.
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.
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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.