Can paracentesis be performed in a patient with ongoing Continuous Therapeutic Thoracentesis (CTT) and ascites?

Paracentesis in Patients with Ascites and Ongoing Coagulopathy

Yes, paracentesis can and should be performed safely in patients with ascites regardless of coagulopathy status, including those on continuous therapeutic anticoagulation (CTT). 1, 2

Safety Profile with Coagulopathy

Paracentesis is remarkably safe even with severe coagulopathy, with bleeding complications occurring in less than 1 in 1,000 procedures. 2, 3

• Paracentesis has been safely performed in patients with INR as high as 8.7 and platelet counts as low as 19,000 cells/mm³ without prophylactic transfusions 2, 3
• The mean INR in a large series of 1,100 paracenteses was 1.7 ± 0.46 (range 0.9-8.7), with mean platelet count of 50.4 × 10³/μL (range 19-341 × 10³/μL), and no significant bleeding complications occurred 3
• When bleeding does occur, it is more commonly associated with renal failure rather than coagulopathy itself 2

Key Contraindications (What Actually Matters)

The only true contraindications to paracentesis are: 2

• Clinically evident hyperfibrinolysis with three-dimensional ecchymosis or hematoma formation 2
• Clinically evident disseminated intravascular coagulation 2

Coagulopathy from anticoagulation or liver disease is NOT a contraindication. 1, 2

Technical Approach to Minimize Risk

Use the left lower quadrant as the preferred site: 2

• Position: 2 finger breadths (3 cm) cephalad and 2 finger breadths medial to the anterior superior iliac spine 2
• This location has thinner abdominal wall and larger fluid pools compared to midline approaches 2
• Avoid visible collateral vessels and the inferior/superior epigastric arteries (located midway between pubis and anterior superior iliac spines) 2

Volume Expansion Requirements

For large-volume paracentesis (>5 L), albumin administration is mandatory: 1

• Administer 8 g albumin per liter of ascites removed (approximately 100 mL of 20% albumin per 3 L ascites) 1
• This prevents post-paracentesis circulatory dysfunction and reduces AKI risk 1
• In patients with acute-on-chronic liver failure (ACLF), give 6-8 g/L regardless of volume removed 1

Common Pitfall to Avoid

Do NOT routinely check or correct coagulation parameters before paracentesis. 4, 2

• Routine measurement of PT/INR and platelet count is not recommended before therapeutic paracentesis 4
• Prophylactic fresh frozen plasma or platelet transfusions are not recommended 4
• These interventions add cost, delay care, and provide no proven benefit 2, 3

Clinical Context

The question likely refers to "CTT" as coagulopathy/coagulation therapy rather than "Continuous Therapeutic Thoracentesis," as the latter term is not standard medical terminology. Regardless, the safety data applies to patients with any degree of coagulopathy from anticoagulation, liver disease, or other causes. 2, 3