From the Guidelines
Paracentesis is contraindicated in patients with uncooperative behavior, abdominal skin infection at the proposed puncture site, pregnancy, severe coagulopathy, and severe bowel distension. When considering paracentesis, it is essential to weigh the potential benefits against the risks of complications, such as bowel perforation, significant bleeding, infection, and fluid leakage. According to the most recent and highest quality study 1, absolute contraindications to paracentesis include severe coagulopathy, such as accelerated fibrinolysis or disseminated intravascular coagulation.
Key Contraindications
- Uncooperative patient
- Abdominal skin infection at the proposed puncture site
- Pregnancy
- Severe coagulopathy (accelerated fibrinolysis or disseminated intravascular coagulation)
- Severe bowel distension
While mild coagulopathy may not be an absolute contraindication, correction with fresh frozen plasma or platelets may be necessary before proceeding, as suggested by 1. However, routine tests of coagulation do not reflect bleeding risk in patients with cirrhosis, and prophylactic transfusions may not be necessary in all cases 1. The procedure should always be performed under ultrasound guidance when possible to minimize risks, especially in patients with any relative contraindications.
Relative Contraindications
- Pregnancy
- Distended bowel
- Previous abdominal surgery near the puncture site
- Uncorrected bleeding disorders
- Severe skin infections at the insertion site
In patients with severe coagulopathy who urgently need paracentesis, alternative approaches such as transjugular paracentesis or ultrasound-guided procedures with smaller needles may be considered, as mentioned in 1. Ultimately, the decision to perform paracentesis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, as well as the potential benefits of the procedure.
From the Research
Contraindications to Paracentesis
- The use of direct oral anticoagulants (DOACs) such as apixaban may increase the risk of bleeding complications after paracentesis 2, 3
- High doses of apixaban, co-prescription of apixaban with other antiplatelet or anticoagulant medications, and apixaban taken within six hours of the procedure may be associated with a higher risk of bleeding 2
- Inpatient status may also be associated with a higher risk of bleeding after paracentesis 2
- Patients with cirrhosis and coagulopathy may be at risk of bleeding after paracentesis, but the overall risk is low 4
- The use of thromboelastography (TEG) before paracentesis may help identify patients at risk of procedure-related bleeding and reduce transfusion requirements 4
Anticoagulation Management
- There is no consensus on whether to continue or stop systemic anticoagulation before paracentesis 5
- Continuous aspirin and clopidogrel may be permissible for diagnostic and therapeutic paracentesis and diagnostic endoscopy 5
- Plasma transfusion should be avoided for all paracenteses and diagnostic endoscopy, unless there is a high risk of bleeding 5
- Prophylactic platelet transfusions may not be necessary for outpatient diagnostic paracentesis and diagnostic endoscopy, unless the platelet count is below 20,000/mm^3 5
Safety of Paracentesis with Anticoagulation
- Abdominal paracentesis appears to be safe in hospitalized patients receiving therapeutic or prophylactic anticoagulation, with low rates of bleeding complications and thrombotic complications 6
- Withholding anticoagulation periprocedurally may not be necessary, but the decision should be made on a case-by-case basis 6