{"id":25568,"date":"2019-09-02T18:08:43","date_gmt":"2019-09-02T22:08:43","guid":{"rendered":"http:\/\/www.stepwards.com\/?page_id=25568"},"modified":"2025-03-21T22:49:17","modified_gmt":"2025-03-22T02:49:17","slug":"interventional-radiology-procedures-paracentesis-holding-anticoagulation-prior-to-the-procedure","status":"publish","type":"page","link":"https:\/\/www.stepwards.com\/?page_id=25568","title":{"rendered":"Radiology Procedures: Paracentesis (Anticoagulation\/Antithrombotic Medication Management)"},"content":{"rendered":"<div id=\"toc_container\" class=\"no_bullets\"><p class=\"toc_title\">Page Contents<\/p><ul class=\"toc_list\"><li><a href=\"#OVERVIEW\"><span class=\"toc_number toc_depth_1\">1<\/span> OVERVIEW<\/a><\/li><li><a href=\"#WHAT_CLASSES_OF_MEDICATIONS_SHOUDL_BE_CONSIDERED\"><span class=\"toc_number toc_depth_1\">2<\/span> WHAT CLASSES OF MEDICATIONS SHOUDL BE CONSIDERED?<\/a><\/li><li><a href=\"#WHAT_IS_THE_OVERALL_BLEEDING_RISK_ASSOCIATED_WITH_A_PARACENTESIS\"><span class=\"toc_number toc_depth_1\">3<\/span> WHAT IS THE OVERALL BLEEDING RISK ASSOCIATED WITH A PARACENTESIS?<\/a><\/li><li><a href=\"#AMERICAN_JOURNAL_OF_ROENTGENOLOGY_AJR_2015_GUIDELINES_MORE_CONSERVATIVE\"><span class=\"toc_number toc_depth_1\">4<\/span> AMERICAN JOURNAL OF ROENTGENOLOGY (AJR) 2015 GUIDELINES: MORE CONSERVATIVE<\/a><\/li><li><a href=\"#SOCIETY_OF_INTERVENTIONAL_RADIOLOGY_SIR_2019_CONSENSUS_GUIDELINES\"><span class=\"toc_number toc_depth_1\">5<\/span> SOCIETY OF INTERVENTIONAL RADIOLOGY (SIR) 2019 CONSENSUS GUIDELINES<\/a><\/li><li><a href=\"#REFERENCES\"><span class=\"toc_number toc_depth_1\">6<\/span> REFERENCES<\/a><\/li><\/ul><\/div>\n<h5><span id=\"OVERVIEW\"><span style=\"text-decoration: underline;\">OVERVIEW<\/span><\/span><\/h5>\n<p>While a paracentesis is not a &#8220;high risk&#8221; 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 <a href=\"http:\/\/www.stepwards.com\/?page_id=25572\">anticoagulation\/antithrombotic medication management and be found here<\/a>.<\/p>\n<figure style=\"width: 769px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" src=\"https:\/\/cdn.pixabay.com\/photo\/2016\/11\/23\/15\/03\/medications-1853400_1280.jpg\" alt=\"Free Medications Tablets photo and picture\" width=\"779\" height=\"519\" \/><figcaption class=\"wp-caption-text\">There are many different anticoagulation medications to consider, when thinking about minimizing the patient&#8217;s bleeding risk peri-procedurally (<a href=\"https:\/\/cdn.pixabay.com\/photo\/2016\/11\/23\/15\/03\/medications-1853400_1280.jpg\">image source<\/a>)<\/figcaption><\/figure>\n<p>Keep in mind that anticoagulation\/antithrombotic medications are one component of evaluating a patient&#8217;s bleeding risk prior to a paracentesis, another component are <a href=\"http:\/\/www.stepwards.com\/?page_id=26005\">key laboratory values that are explained more on a separate page here<\/a>.<\/p>\n<h5><span id=\"WHAT_CLASSES_OF_MEDICATIONS_SHOUDL_BE_CONSIDERED\"><span style=\"text-decoration: underline;\">WHAT CLASSES OF MEDICATIONS SHOUDL BE CONSIDERED?<\/span><\/span><\/h5>\n<p>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):<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>Anticoagulant Medications:<\/strong><\/span><\/p>\n<ul>\n<li><strong>Vitamin K antagonists:\u00a0<\/strong>classically Warfarin\/Coumadin falls in this category.<\/li>\n<li><strong>Heparins:\u00a0<\/strong>there are a few types of heparins:\n<ul>\n<li><strong>Low molecular weight: <\/strong>Enoxaparin, Dalteparin<\/li>\n<li><strong>Unfractionated:\u00a0<\/strong>often just called unfractionated heparin<\/li>\n<\/ul>\n<\/li>\n<li><strong>Direct thrombin inhibitors:\u00a0<\/strong>Argatroban, Bivalirudin, Dabigatran<\/li>\n<li><strong>Factor Xa Inhibitors:\u00a0<\/strong>Apixaban, Betrixaban, Edoxaban, Fondaparinux, Rivaroxaban<\/li>\n<\/ul>\n<p><span style=\"text-decoration: underline;\"><b style=\"text-decoration-line: underline;\"><\/b><b><u>Anti-platelet<\/u><\/b><b style=\"text-decoration-line: underline;\"> Medications:<\/b><\/span><\/p>\n<ul>\n<li><strong>NSAIDs: <\/strong>Aspirin, Ibuprofen, Indomethacin, Ketorolac, etc.<\/li>\n<li><strong>Thienopyridines:\u00a0<\/strong>Clopidogrel, Cangrelor, Prasugrel etc.<\/li>\n<li><strong>Glycoprotein IIb\/IIIa inhibitors:<\/strong> Abciximab, Eptifibatide, Tirofiban<\/li>\n<li><strong>Phosphodiesterase inhibitors:\u00a0<\/strong>Cilostazol, Dipyridamole<\/li>\n<\/ul>\n<h5><span id=\"WHAT_IS_THE_OVERALL_BLEEDING_RISK_ASSOCIATED_WITH_A_PARACENTESIS\"><span style=\"text-decoration: underline;\">WHAT IS THE OVERALL BLEEDING RISK ASSOCIATED WITH A PARACENTESIS?<\/span><\/span><\/h5>\n<p>The bleeding risk of a paracentesis is pretty much universally considered to be low, and for anticoagulation guidelines, this procedure is characterized as <strong>&#8220;low risk for bleeding&#8221;\u00a0<\/strong> which helps inform our practices with regards to peri-procedural anticoagulation.<\/p>\n<h5><span id=\"AMERICAN_JOURNAL_OF_ROENTGENOLOGY_AJR_2015_GUIDELINES_MORE_CONSERVATIVE\"><span style=\"text-decoration: underline;\">AMERICAN JOURNAL OF ROENTGENOLOGY (AJR) 2015 GUIDELINES: MORE CONSERVATIVE<\/span><\/span><\/h5>\n<p>For many radiologists, the <a href=\"https:\/\/www.ajronline.org\/doi\/full\/10.2214\/AJR.14.13342\">AJR 2015<\/a> 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.<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>Anticoagulant Medications:<\/strong><\/span><\/p>\n<ul>\n<li><strong>Vitamin K antagonists (Warfarin):\u00a0<\/strong>hold for 5 days before the procedure.<\/li>\n<li><strong>Heparins:<\/strong>\n<ul>\n<li><strong>Low molecular weight (SQ): <\/strong>hold 12 hours before procedure<\/li>\n<li><strong>Unfractionated (IV):\u00a0<\/strong>hold 1 hour before procedure<\/li>\n<li><strong>Unfractionated (SQ):\u00a0<\/strong>hold 4 hours before procedure<\/li>\n<\/ul>\n<\/li>\n<li><strong>Direct thrombin inhibitors (Dabigatran): <\/strong>hold 24 hours prior to procedure<\/li>\n<li><strong>Factor Xa Inhibitors (Apixiban, Fondaparinux, Rivaroxaban): <\/strong>hold 24 hours prior to procedure<\/li>\n<\/ul>\n<p><span style=\"text-decoration: underline;\"><b style=\"text-decoration-line: underline;\"><\/b><b><u>Anti-platelet<\/u><\/b><b style=\"text-decoration-line: underline;\"> Medications:<\/b><\/span><\/p>\n<ul>\n<li><strong>Aspirin:\u00a0<\/strong>don&#8217;t hold<\/li>\n<li><strong>NSAIDs:\u00a0<\/strong>don&#8217;t hold<\/li>\n<li><strong>Thienopyridines (Clopidogrel,Prasugrel): <\/strong>hold 5 days prior to the procedure.<\/li>\n<li><strong>Glycoprotein IIb\/IIIa inhibitors:<\/strong> no recommendation.<\/li>\n<li><strong>Phosphodiesterase inhibitors (Cilostazol):\u00a0<\/strong>don&#8217;t hold<\/li>\n<li><strong>Aspirin and Dipyridamole:\u00a0<\/strong>hold 2 days before the procedure<\/li>\n<\/ul>\n<h5><span id=\"SOCIETY_OF_INTERVENTIONAL_RADIOLOGY_SIR_2019_CONSENSUS_GUIDELINES\"><span style=\"text-decoration: underline;\">SOCIETY OF INTERVENTIONAL RADIOLOGY (SIR) 2019 CONSENSUS GUIDELINES<\/span><\/span><\/h5>\n<p>It is important to appreciate that many criticized the AJR guidelines for being toor restrictive and conservative, and <a href=\"https:\/\/www.jvir.org\/article\/S1051-0443(19)30407-5\/fulltext\">in 2019 the SIR created an updated consensus guidelines<\/a> regarding this topic. They were not as conservative, so much to the point that for a procedure like a paracentesis that is &#8220;low risk for bleeding&#8221; there are very few instances where anticoagulation should be held. These are listed below:<\/p>\n<ul>\n<li><strong>Warfarin:\u00a0<\/strong>target INR \u2264 3.0 (hold\/modify\/and bridge if INR above this value pre-procedure).<\/li>\n<li><strong>Cangrelor (Kengreal):\u00a0<\/strong>defer until patient is off this medication, if emergent, withhold 1 hour before procedure (recommend discussion with cardiology)<\/li>\n<li><strong>Long-acting Abciximab (ReoPro<\/strong>):\u00a0hold 24 hours before procedure<\/li>\n<li><strong>Short-acting Eptifibatide (Integrilin)<\/strong>: hold 4-8 hours before the procedure<\/li>\n<\/ul>\n<p><span style=\"text-decoration: underline;\"><b style=\"text-decoration-line: underline;\">*For <\/b><b><u>most<\/u><\/b><b style=\"text-decoration-line: underline;\"> all instances, with these 2019 SIR guidelines, anticoagulation <\/b><b><u>should<\/u><\/b><b style=\"text-decoration-line: underline;\"> not be held for a low risk procedure like a paracentesis.\u00a0<\/b><\/span><\/p>\n<h5><span id=\"REFERENCES\"><span style=\"text-decoration: underline;\">REFERENCES<\/span><\/span><\/h5>\n<p><strong>The following sources were utilized when creating the content on this page:<\/strong><\/p>\n<p><a href=\"https:\/\/www.ajronline.org\/doi\/full\/10.2214\/AJR.14.13342\"><strong>Management of Anticoagulant and Antiplatelet Medications in Adults Undergoing Percutaneous Interventions<\/strong><\/a><\/p>\n<p><a href=\"https:\/\/www.jvir.org\/article\/S1051-0443(19)30406-3\/fulltext\"><span style=\"text-decoration: underline;\"><strong>Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions\u2014Part I: Review of Anticoagulation Agents and Clinical Considerations<\/strong><\/span><\/a><\/p>\n<p><span style=\"text-decoration: underline;\"><strong><a href=\"https:\/\/www.jvir.org\/article\/S1051-0443(19)30407-5\/fulltext\">Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions\u2014Part II: Recommendations<\/a><\/strong><\/span><\/p>\n<p>&nbsp;<\/p>\n<pre>Page Updated: 09.01.2019<\/pre>\n","protected":false},"excerpt":{"rendered":"<p>Page Contents1 OVERVIEW2 WHAT CLASSES OF MEDICATIONS SHOUDL BE CONSIDERED?3 WHAT IS THE OVERALL BLEEDING RISK ASSOCIATED WITH A PARACENTESIS?4 AMERICAN JOURNAL OF ROENTGENOLOGY (AJR) 2015 GUIDELINES: MORE CONSERVATIVE5 SOCIETY OF INTERVENTIONAL RADIOLOGY (SIR) 2019 CONSENSUS GUIDELINES6 REFERENCES OVERVIEW While a paracentesis is not a &#8220;high risk&#8221; procedure when it comes to bleeding, there are &#8230; <a title=\"Radiology Procedures: Paracentesis (Anticoagulation\/Antithrombotic Medication Management)\" class=\"read-more\" href=\"https:\/\/www.stepwards.com\/?page_id=25568\" aria-label=\"More on Radiology Procedures: Paracentesis (Anticoagulation\/Antithrombotic Medication Management)\">Read more<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":25159,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_mi_skip_tracking":false},"jetpack_shortlink":"https:\/\/wp.me\/P71awf-6Eo","_links":{"self":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/25568"}],"collection":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=25568"}],"version-history":[{"count":12,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/25568\/revisions"}],"predecessor-version":[{"id":28733,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/25568\/revisions\/28733"}],"up":[{"embeddable":true,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/25159"}],"wp:attachment":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=25568"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}