Is paracentesis safe in patients with elevated International Normalized Ratio (INR)?

Paracentesis is Safe in Patients with Elevated INR Without Routine Correction

Paracentesis can be safely performed in patients with cirrhosis and elevated INR without routine prophylactic correction with fresh frozen plasma (FFP) or platelet transfusions. 1 The bleeding risk remains extremely low (<1.5%) even with significant coagulopathy, and routine blood product administration is not supported by evidence. 1

Key Evidence Against Routine INR Correction

Guidelines Recommend Against Prophylactic Blood Products

• The AGA explicitly recommends against routine use of FFP or platelets for bleeding prophylaxis in patients with stable cirrhosis undergoing paracentesis. 1
• The EASL guidelines state there are no data to support the use of FFP or pooled platelets before paracentesis, even with severe coagulopathy (prothrombin activity <40%) and/or thrombocytopenia (<40,000/μL). 1
• Multiple guidelines emphasize that paracentesis does not routinely require coagulation assessment before performance. 1

Bleeding Rates Are Extremely Low Regardless of INR

• In a large retrospective study of 3,116 paracenteses performed without prophylactic correction (mean INR 1.6, with 14% having INR >2), only 6 bleeding events (0.19%) occurred. 2
• A study of 1,100 paracenteses found zero bleeding events in procedures performed with platelets <50×10⁹/L and INR >1.5. 1
• Even in patients with severe coagulopathy, only 2 minor cutaneous bleedings occurred out of 142 paracenteses in patients with INR >1.5 and platelets <50,000/μL. 1

Why INR Does Not Predict Bleeding Risk in Cirrhosis

The Rebalanced Hemostasis Concept

• Patients with stable cirrhosis have a "rebalanced" hemostatic system where both pro-coagulant and anti-coagulant factors are proportionally reduced. 1
• The INR was designed to monitor warfarin therapy, not to assess bleeding risk in liver disease, and correlates poorly with actual bleeding risk during procedures. 1
• No specific PT/INR threshold has been identified that defines an unacceptable bleeding risk for paracentesis. 1

Blood Products May Actually Increase Risk

• FFP transfusion increases portal pressure and intravascular volume, which may paradoxically increase bleeding risk rather than reduce it. 1
• The large volume of FFP required to reach arbitrary INR targets has minimal effect on thrombin generation and carries significant risks including transfusion-related acute lung injury, infection transmission, and transfusion-associated circulatory overload. 1
• Blood product transfusions can exacerbate portal hypertension, which is itself a risk factor for bleeding. 1

When to Exercise Caution

High-Risk Scenarios Requiring Vigilance

• Acute kidney injury is the only independent risk factor consistently associated with post-paracentesis bleeding and should prompt heightened awareness. 1
• Patients with acute-on-chronic liver failure or decompensated liver disease with progressive consumptive coagulopathy may represent exceptions where management differs. 1
• Patients on therapeutic anticoagulation (warfarin, heparin, DOACs) require separate consideration and may have increased bleeding risk. 1

Severe Coagulopathy Considerations

• While routine correction is not recommended, disseminated intravascular coagulation is a contraindication to paracentesis. 1
• In patients with platelet count <30×10⁹/L, fibrinogen <0.6 g/L, and aPTT >100 seconds, these are the strongest predictors for major bleeding and all but essential procedures should be avoided. 1

Practical Approach to Paracentesis in Elevated INR

Pre-Procedure Assessment

• Check baseline INR and platelet count for documentation purposes, not to guide prophylactic transfusion decisions. 1
• Assess for acute kidney injury, which is the primary modifiable risk factor for bleeding. 1
• Evaluate for signs of decompensation or acute-on-chronic liver failure rather than focusing on coagulation parameters. 1

Technique Optimization

• Use real-time ultrasound guidance, which has been associated with near-zero hemorrhage risk (0.19%) without coagulation correction. 2
• Perform under strict sterile conditions using disposable sterile materials. 1
• Avoid paracentesis in the presence of loculated ascites. 1

Post-Procedure Monitoring

• Monitor for bleeding complications for at least 2 weeks post-procedure. 2
• Be aware that hemorrhagic complications, when they occur, are most commonly abdominal wall hematomas (52%) or hemoperitoneum (41%). 3
• If bleeding occurs, interventional radiology-guided transcatheter coiling/embolization is superior to surgical intervention with significantly lower 30-day mortality. 3

Common Pitfalls to Avoid

• Do not routinely transfuse FFP or platelets based solely on elevated INR or low platelet counts - this practice increases costs, delays procedures, and may worsen outcomes. 1
• Do not assume that correcting INR to "normal" ranges will reduce bleeding risk - no evidence supports commonly used thresholds for INR correction. 1
• Do not withhold necessary paracentesis due to coagulopathy concerns in stable cirrhosis patients - the procedure itself carries minimal risk. 1
• Do not overlook acute kidney injury as the primary modifiable bleeding risk factor. 1

Cost and Resource Considerations

• Avoiding routine prophylactic transfusions resulted in cost savings of $816,000 in one institutional study, with avoidance of 1,125 units of FFP and 366 units of platelets. 2
• Implementation of less stringent coagulation parameters (INR ≤2.0, platelets ≥25×10⁹/L versus historical INR ≤1.5, platelets ≥50×10⁹/L) was associated with fewer hemorrhagic complications and significant decrease in preprocedural FFP/platelet administration. 1