From the Guidelines
Paracentesis can generally be performed safely in patients on Eliquis (apixaban) without discontinuation of the medication. For non-emergent paracentesis, continuing Eliquis is reasonable as the procedure carries a low bleeding risk, especially when performed with ultrasound guidance 1. No specific reversal or bridging is typically required before the procedure. However, if there are additional bleeding risk factors (such as thrombocytopenia, coagulopathy, or concurrent use of other anticoagulants), consider checking coagulation parameters before proceeding.
- The risk of bleeding complications from paracentesis is low, with a reported incidence of about 1% 1.
- The use of small-gauge needles and ultrasound guidance minimizes tissue trauma and reduces the risk of bleeding.
- For patients with very high bleeding risk, one could consider holding a single dose of Eliquis before the procedure, though this is rarely necessary, as the 2014 AHA/ACC/HRS guideline suggests that holding anticoagulation for 1 day may be sufficient for patients with normal renal function 1. After paracentesis, monitor the puncture site for bleeding or hematoma formation for at least 2 hours.
- The safety of continuing direct oral anticoagulants during paracentesis is supported by the procedure's low bleeding risk profile and the use of small-gauge needles that minimize tissue trauma.
- If significant bleeding occurs post-procedure, Andexanet alfa can be used as a reversal agent for apixaban, though this is rarely needed for paracentesis-related bleeding. Key considerations for paracentesis in patients on Eliquis include:
- Avoiding the area of the inferior epigastric arteries and visible collaterals to minimize the risk of bleeding.
- Using the left lower quadrant as the preferred location for needle insertion, as it has been shown to be thinner and with a larger pool of fluid than the midline 1.
From the Research
Paracentesis on Eliquis: Key Findings
- The risk of bleeding after paracentesis for patients taking apixaban (Eliquis) is higher than historical estimates, with a reported rate of 5.5% in one study 2.
- Factors associated with an increased risk of bleeding include high doses of apixaban, co-prescription with other antiplatelet or anticoagulant medications, and apixaban taken within six hours of the procedure 2.
- Case reports have highlighted the risk of severe bleeding complications in patients with cirrhosis taking apixaban who undergo paracentesis, suggesting that further investigation into the safety of this procedure in these patients is warranted 3.
Management of Bleeding Risk
- Tranexamic acid (TXA) has been shown to be safe and effective in reducing bleeding-related mortality, with no increased risk of thrombotic events 4, 5.
- The use of TXA may be considered as a strategy to mitigate the risk of bleeding in patients undergoing paracentesis while taking apixaban.
Nursing Care for Patients Undergoing Paracentesis
- Nurses play a crucial role in monitoring patients throughout the procedure, administering treatment as directed, and removing the drain at the end of the procedure 6.
- Knowledge of the benefits and risks of paracentesis is essential to provide safe, evidence-based care for patients undergoing this procedure 6.