Do I need to hold heparin (unfractionated heparin/low molecular weight heparin) before paracentesis?

Heparin Management Before Paracentesis

Prophylactic doses of heparin (unfractionated heparin/low molecular weight heparin) should be held for 24 hours before paracentesis due to the risk of bleeding complications.

Risk Assessment for Paracentesis

• Paracentesis is considered a procedure with potential bleeding risk, particularly when performed in patients on anticoagulation therapy 1
• A case report documented a life-threatening rectus sheath hematoma with hypotension following paracentesis in a patient receiving prophylactic unfractionated heparin 1
• The risk of bleeding during invasive procedures is related to the type of procedure, the ability to control bleeding, and the potential morbidity of bleeding 2

Timing of Heparin Discontinuation

• For procedures with bleeding risk like paracentesis:

  • Prophylactic doses of unfractionated heparin (UFH) should be held for at least 5 hours before the procedure 2
  • Low molecular weight heparin (LMWH) prophylactic doses should be held for at least 12 hours before the procedure 2
  • Therapeutic doses of LMWH should be held for 24 hours before the procedure 2

• For patients at high thrombotic risk receiving therapeutic anticoagulation:

  • UFH has a short half-life and can be discontinued approximately 5 hours before the procedure 2
  • LMWH should be discontinued at least 24 hours before the procedure due to its longer half-life 2

Thrombotic Risk Stratification

• Low thrombotic risk patients (no venous thromboembolic events for >3 months, atrial fibrillation without history of stroke, bileaflet mechanical valve in aortic position) can safely have anticoagulation held without bridging 2
• High thrombotic risk patients (recent thromboembolic event, mechanical mitral valve, older model cardiac valves) may require bridging therapy 2
• Bridging therapy with heparin is associated with increased bleeding risk without significant reduction in thromboembolic events compared to simply holding anticoagulation 3

Resumption of Anticoagulation After Paracentesis

• For prophylactic doses, heparin can typically be resumed 24 hours after the procedure if adequate hemostasis is achieved 2
• For therapeutic doses in high-risk patients, heparin can be resumed 24-48 hours after the procedure, depending on the bleeding risk assessment 2
• Oral anticoagulants can be resumed on day 1 or 2 after the procedure depending on hemostasis adequacy 2

Special Considerations

• Patients with renal impairment may require longer periods of LMWH discontinuation due to delayed clearance 2
• For emergency paracentesis in anticoagulated patients, reversal of anticoagulation should be considered based on the urgency of the procedure and the patient's thrombotic risk 2
• The decision to bridge with heparin during temporary discontinuation of oral anticoagulants should be based on individual thrombotic risk assessment, as bridging increases bleeding risk without clear thrombotic benefit 3

Practical Recommendations

• Hold prophylactic UFH for at least 5 hours before paracentesis 2
• Hold prophylactic LMWH for at least 12 hours before paracentesis 2
• Hold therapeutic anticoagulation for 24 hours before paracentesis 2
• Resume anticoagulation 24 hours after the procedure if adequate hemostasis is achieved 2
• Monitor for signs of bleeding after the procedure, particularly in the rectus sheath area 1