Paracentesis and Coagulopathies


Dr. Ethan Szpara

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 (K-Bomb):

  • 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.