Diagnostic Paracentesis and Bleeding Risk Can paracentesis be

Diagnostic Paracentesis and Bleeding Risk Can paracentesis be performed safely without transfusion in cases of elevated INR and decreased platelet count? Colleen M. Donovan, MD July 23, 2008

Studies Grabau CM, Crago SF, Hoff LK, et al. Performance standards for therapeutic abdominal paracentesis. Hepatology 2004, 40: 484 -488 Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther 2005, 21: 525 -529 Lin CH, Shih FY, Ma MH, Chiang WC, Yang CW, Ko PC. Should bleeding tendency deter abdominal paracentesis? Digestive & Liver Disease 2005, 37(12): 946 -951

Grabau et al Retrospective study Outpatient Population: 1, 100 large volume (mean = 8. 7 L + 2. 8 L)) paracenteses in 628 patients over a 7 year period (June 1994 -June 2001) Excluded patients with fibrinolysis/DIC – no patients met this criteria 513 patients with cirrhotic ascities, 91 patients with malignant ascities, 24 with “other. ” PT/INR and Platelet counts measured within 72 hours for most patients, and within 7 -14 days for 27 patients Hepatology 2004, 40: 484 -488

Grabau et al: Results Number of patients INR 277 < 1. 4 531 1. 5 -2. 0 208 2. 1 -2. 5 84 MEAN > 2. 5 1. 7 + 0. 46 INR Range = 0. 9 - 8. 7 Hepatology 2004, 40: 484 -488

Grabau et al: Results Number of patients 210 292 361 188 48 1 MEAN Platelet count (x 103/m. L) > 60 50 -59 40 -49 30 -39 20 -29 < 20 50. 4 Platelet range = 19 - 341 Hepatology 2004, 40: 484 -488

Grabau et al: Complications Postural Hypotension (3 patients) Leakage of ascitic fluid (4 patients) Hemorrhage (1 patient, 1 episode) – plts 64 x 103/m. L, INR not mentioned – improved prior to dc home No complications requiring transfusion or admission Hepatology 2004, 40: 484 -488

Pache et al Retrospective study Population: 4729 abdominal paracenteses over a 10 year period (Jan 1994 – Dec 2003) Excluded patients with fibrinolysis/DIC– no patients met this criteria All comers with ascities except hepatocellular carcinoma – spontaneous hemoperitoneum can occur with this type of liver tumor Aliment Pharmacol Ther 2005, 21: 525 -529

Pache et al: Results MEAN INR 2. 0 + 0. 9 Platelets (x 103/m. L) 102 + 37 Aliment Pharmacol Ther 2005, 21: 525 -529

Pache et al: Complications Severe Hemorrhage in 9 of 4729 paracenteses – hemodynamic instability or > 1. 5 g/d. L drop in Hgb – 6 cases of hemoperitoneum, 3 cases of abdominal wall hematoma – only occurred after > 2 L evacuation – 7/9 died, 6/9 died due to medical reasons other than hemorrhage – All 9 patients also had renal dysfunction Frequently of hemorrhagic complication: 0. 19% Lethal outcome in 1/4729 - 0. 016% – INR 3. 1, plts 120 x 103 /m. L – hemorrhage at 10 h post procedure Aliment Pharmacol Ther 2005, 21: 525 -529

Lin et al Prospective study Emergency Department patients Population: 410 paracenteses in 163 patients over a 2 year period (Jan 2003 – Jan 2005) Excluded patients with fibrinolysis/DIC – no patients met this criteria Digestive & Liver Disease 2005, 37(12): 946 -951

Lin et al: Results INR Therapeutic (N = 314) 199 Number of Complications < 1. 4 Diagnostic (N = 96) 69 1. 5 -1. 9 24 89 0 2. 0 -2. 4 2 13 0 2. 5 -2. 9 1 9 2 > 3. 0 0 4 0 MEAN 1. 4 - 0 142 paras (27 Dx, 115 Tx) – INR > 1. 5 Digestive & Liver Disease 2005, 37(12): 946 -951

Lin et al: Results Platelets (x 103/m. L) Diagnostic (N = 96) Therapeutic (N = 314) Number of Complications > 100 65 158 0 50 -99 25 107 2 40 -49 3 29 0 30 -39 2 9 0 20 -29 1 2 0 < 19 0 MEAN 153 142 - 55 paras ( 6 Dx, 49 Tx) – platelets < 50 x 103/m. L Digestive & Liver Disease 2005, 37(12): 946 -951

Hemorrhage in 2 of 410 paracenteses – both instances occurred in the same patient Lin et al: Complications – Minor bleeding (local ecchymosis, cutaneous bleeding) within 3 hours of procedure – Controlled within 10 min with local compression – INR 2. 6, 2. 9, plts 81, 51 – Evacuation of 1. 2 L and 4. 0 L respectively – Incidence: 0. 5% (95% CI = 0. 1 -1. 8%) – 9 other patients with INR > 2. 4 and platelets < 100 experienced no complications. No deaths nor complications requiring transfusion or hospitalization. Digestive & Liver Disease 2005, 37(12): 946 -951

SUMMARY Grabau et al Mean INR Mean Platelets Hemorrhage Incidence 1. 7 50. 4 0. 09% (1/1100) Pache et al 2. 0 102 0. 19% (9/4927) Lin et al 1. 4 (dx) 1. 4 (tx) 153 (dx) 142 (tx) 0. 5% (2/410)

HUPism Unless there is clinical evidence of fibrinolysis or DIC, diagnostic paracentesis can be performed safely in the emergency department despite mild/moderate bleeding risk (INR, platelets) and without transfusion.

Nicaragua May 2008 DOCTOR