Paracentesis Indications for Blood Products

Transfusion Thresholds

Coagulopathy

  • Most cirrhotics with abnormal coagulation studies do not require a transfusion1-3
  • INR does not accurately reflect the bleeding risk in cirrhotics4
    • Decreased liver synthesis of pro-coagulant factors is often balanced by the decreased synthesis of anti-coagulants. There is also a compensatory elevation in Factor VIII and Von Willebrand factor. This complex milieu is not accurately reflected by an INR or aPTT. 5
    • A more accurate indication of bleeding risk is clinically apparent bleeding like an active GI bleed, epistaxis, oozing around IV’s, or large hematomas
  • In general, the goal INR < 2.5
    • 1,000 consecutive outpatient paracenteses had no bleeding complications despite 67% of patients having an INR 1.5-2.56
    • 50% of hepatologist never use FFP prior to paracentesis, or only use FFP if the INR > 2.51

Thrombocytopenia

  • In general, the goal platelets > 30,000
    • Absolute platelet count in cirrhotics also does not predict bleeding risk
    • 1,000 consecutive outpatient paracenteses had no bleeding complications despite 50% of patients having  platelets between 30,00-50,0006
    • Platelet function is upregulated in cirrhotics by an abundance of Factor VIII and Von Willebrand factor5
  • Qualitative platelet defects do predict severe bleeding7
    • Consider DDAVP, platelet transfusion, small gauge needle, and/or delaying paracentesis if
      • Uremic renal failure
      • Aspirin or other antiplatelet agent

High Bleeding Risk

Avoid paracentesis in cirrhotics with DIC and Hyperfibrinolysis3

  • Disseminated Intravascular Coagulation
    • Difficult to diagnose in cirrhotics because of the abnormal fibrinogen, platelets, and coagulation studies at baseline
    • Look for schistocytes or reduced Factor VIII levels
    • Transfuse FFP and cryoprecipitate as needed
  • Fibrinolysis
    • Up to 30% of cirrhotics in ICU have hyperfibrinolysis8
    • Low fibrinogen alone is not diagnostic
      • Euglobulin lysis is diagnostic, but takes 4-7 days to result
    • Clinical Signs
      • Suspect hyperfibrinolysis if clinically significant mucosal bleeding or massive bruising
      • Post procedure bleeding that is delayed by several hours is classic for hyperfibrinolysis
        • The initial platelet plug is functional, but then breaks down as fibrin is lysed
      • Transfuse cryoprecipitate and use Aminocaproic Acid as needed

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References

  1. Runyon, B.A. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 49, 2087-107 (2009).
  2. Thomsen, T.W., Shaffer, R.W., White, B. & Setnik, G.S. Videos in clinical medicine. Paracentesis. N Engl J Med 355, e21 (2006).
  3. Wong, C.L., Holroyd-Leduc, J., Thorpe, K.E. & Straus, S.E. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA 299, 1166-78 (2008).
  4. Ewe, K. Bleeding after liver biopsy does not correlate with indices of peripheral coagulation. Dig Dis Sci 26, 388-93 (1981).
  5. Tripodi, A. & Mannucci, P.M. The coagulopathy of chronic liver disease. N Engl J Med 365, 147-56 (2011).
  6. Grabau, C.M. et al. Performance standards for therapeutic abdominal paracentesis. Hepatology 40, 484-8 (2004).
  7. Pache, I. & Bilodeau, M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther 21, 525-9 (2005).
  8. Hu, K.Q., Yu, A.S., Tiyyagura, L., Redeker, A.G. & Reynolds, T.B. Hyperfibrinolytic activity in hospitalized cirrhotic patients in a referral liver unit. Am J Gastroenterol 96, 1581-6 (2001).