Sunday, January 08, 2017

Managing peri-procedural hemorrhage risk

Here is a recent review in Chest.

The abstract lists the procedures considered in the review:

Central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture constitute a majority of the procedures performed in patients who are hospitalized.

Of particular interest is the controversy around patients with coagulopathy, either inherent or due to anticoagulants. There is no evidence, and no recommendation from the review, to support avoidance of necessary procedures or prophylactic factor replacement except for LP. In the case LP, though the risk of bleeding is very low an abundance of caution is advised based on expert opinion and rationale. From the review:

Given the paucity of data regarding optimal platelet levels for LP and the potential risks of hematoma, consensus guidelines recommend platelet count of 50,000/mL or greater, with clinical judgment guiding practice when platelet counts are between 20,000 and 49,000/mL…

Based on expert opinion and observational data, the recommendations suggest that therapeutic systemic anticoagulation be held prior to spinal anesthesia or LP.

Special considerations apply to NOACs. From the review:

Direct oral anticoagulants, such as inhibitors of thrombin or factor Xa, are increasingly being used in place of vitamin K antagonists. At this time, recommendations for periprocedural management of these medications are based on expert opinion. These recommendations include holding direct oral anticoagulants for a 24-hour window before and after low-risk procedures and 5 days prior to high-risk procedures.

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