Radiology Procedures: Paracentesis (Anticoagulation/Antithrombotic Medication Management)

OVERVIEW

While a paracentesis is not a “high risk” procedure when it comes to bleeding, there are still some guidelines that can be taken with regards to holding pharmacological anticoagulation prior to the start of the procedure to try and minimize bleeding risk. More general information on the topic of anticoagulation/antithrombotic medication management and be found here.

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There are many different anticoagulation medications to consider, when thinking about minimizing the patient’s bleeding risk peri-procedurally (image source)

Keep in mind that anticoagulation/antithrombotic medications are one component of evaluating a patient’s bleeding risk prior to a paracentesis, another component are key laboratory values that are explained more on a separate page here.

WHAT CLASSES OF MEDICATIONS SHOUDL BE CONSIDERED?

When thinking about pharmacological anticoagulation there are a few key medications/medication categories that should be considered. These categorizations make it easier to follow the guidelines (which typically have recommendations organized by the same category/drug classes listed below):

Anticoagulant Medications:

  • Vitamin K antagonists: classically Warfarin/Coumadin falls in this category.
  • Heparins: there are a few types of heparins:
    • Low molecular weight: Enoxaparin, Dalteparin
    • Unfractionated: often just called unfractionated heparin
  • Direct thrombin inhibitors: Argatroban, Bivalirudin, Dabigatran
  • Factor Xa Inhibitors: Apixaban, Betrixaban, Edoxaban, Fondaparinux, Rivaroxaban

Anti-platelet Medications:

  • NSAIDs: Aspirin, Ibuprofen, Indomethacin, Ketorolac, etc.
  • Thienopyridines: Clopidogrel, Cangrelor, Prasugrel etc.
  • Glycoprotein IIb/IIIa inhibitors: Abciximab, Eptifibatide, Tirofiban
  • Phosphodiesterase inhibitors: Cilostazol, Dipyridamole
WHAT IS THE OVERALL BLEEDING RISK ASSOCIATED WITH A PARACENTESIS?

The bleeding risk of a paracentesis is pretty much universally considered to be low, and for anticoagulation guidelines, this procedure is characterized as “low risk for bleeding”  which helps inform our practices with regards to peri-procedural anticoagulation.

AMERICAN JOURNAL OF ROENTGENOLOGY (AJR) 2015 GUIDELINES: MORE CONSERVATIVE

For many radiologists, the AJR 2015 guidelines have served as a reference when deciding how to hold anticoagulation before a procedure. It is important to keep in mind that some newer recommendations are not as conservative as these ones, however below are this set of recommendations for a low bleeding risk procedure like a paracentesis.

Anticoagulant Medications:

  • Vitamin K antagonists (Warfarin): hold for 5 days before the procedure.
  • Heparins:
    • Low molecular weight (SQ): hold 12 hours before procedure
    • Unfractionated (IV): hold 1 hour before procedure
    • Unfractionated (SQ): hold 4 hours before procedure
  • Direct thrombin inhibitors (Dabigatran): hold 24 hours prior to procedure
  • Factor Xa Inhibitors (Apixiban, Fondaparinux, Rivaroxaban): hold 24 hours prior to procedure

Anti-platelet Medications:

  • Aspirin: don’t hold
  • NSAIDs: don’t hold
  • Thienopyridines (Clopidogrel,Prasugrel): hold 5 days prior to the procedure.
  • Glycoprotein IIb/IIIa inhibitors: no recommendation.
  • Phosphodiesterase inhibitors (Cilostazol): don’t hold
  • Aspirin and Dipyridamole: hold 2 days before the procedure
SOCIETY OF INTERVENTIONAL RADIOLOGY (SIR) 2019 CONSENSUS GUIDELINES

It is important to appreciate that many criticized the AJR guidelines for being toor restrictive and conservative, and in 2019 the SIR created an updated consensus guidelines regarding this topic. They were not as conservative, so much to the point that for a procedure like a paracentesis that is “low risk for bleeding” there are very few instances where anticoagulation should be held. These are listed below:

  • Warfarin: target INR ≤ 3.0 (hold/modify/and bridge if INR above this value pre-procedure).
  • Cangrelor (Kengreal): defer until patient is off this medication, if emergent, withhold 1 hour before procedure (recommend discussion with cardiology)
  • Long-acting Abciximab (ReoPro): hold 24 hours before procedure
  • Short-acting Eptifibatide (Integrilin): hold 4-8 hours before the procedure

*For most all instances, with these 2019 SIR guidelines, anticoagulation should not be held for a low risk procedure like a paracentesis. 

REFERENCES

The following sources were utilized when creating the content on this page:

Management of Anticoagulant and Antiplatelet Medications in Adults Undergoing Percutaneous Interventions

Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part I: Review of Anticoagulation Agents and Clinical Considerations

Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations

 

Page Updated: 09.01.2019