No Units of Plasma Required for Paracentesis
Zero units of fresh frozen plasma should be given before paracentesis in this patient. 1
Guideline-Based Recommendation
The most recent and authoritative guidelines explicitly state that routine prophylactic use of fresh frozen plasma or platelets before paracentesis is not recommended (Class III recommendation), regardless of INR or platelet count abnormalities. 1
Why No Plasma is Needed
Paracentesis is a low-risk procedure that does not require correction of coagulopathy:
Multiple guidelines from the American Gastroenterological Association (2019), American Association for the Study of Liver Diseases (2009), and European Association for the Study of the Liver (2006) all agree that paracentesis can be safely performed without correcting INR or platelet counts. 1
Bleeding complications occur in less than 1 in 1,000 paracenteses, even in patients with severe coagulopathy. 1, 2
In a landmark study of 1,100 large-volume paracenteses, there were zero hemorrhagic complications despite platelet counts as low as 19,000/mm³ (54% had counts <50,000), INR values as high as 8.7 (75% had INR >1.5), and no prophylactic transfusions given. 1
This Patient's Specific Parameters
Your patient's values are well within the safe range for paracentesis:
- Hemoglobin 120 g/L: Normal, no anemia
- Platelets 75 × 10⁹/L: Above the threshold where most clinicians would even consider transfusion (<40,000) 1
- INR 1.7: Mild elevation that does not predict bleeding risk in cirrhosis 1
Why Fresh Frozen Plasma Doesn't Work in Cirrhosis
FFP is ineffective and potentially harmful in this setting:
FFP requires large volumes (10-15 mL/kg, approximately 250 mL/unit) to achieve minimal INR correction, which increases portal pressure and risks transfusion-related complications. 1
Research demonstrates that FFP supplementation does not improve thrombin generation in cirrhotic patients, despite modest INR reduction. 3
A randomized trial showed that even when FFP lowered INR by 0.24 points, there was no difference in bleeding outcomes compared to no transfusion. 4
Risks of FFP transfusion include transfusion-related acute lung injury, volume overload, bacterial/viral contamination, HLA antibody development (affecting future transplantation), and increased portal hypertension. 1
Only True Contraindications to Paracentesis
Paracentesis should be avoided only when there is:
- Clinically evident hyperfibrinolysis (three-dimensional ecchymosis or hematoma formation) 1, 2
- Clinically evident disseminated intravascular coagulation 1, 2
Neither of these conditions is suggested by your patient's presentation.
Common Pitfall to Avoid
Do not use INR as a guide for transfusion decisions in cirrhosis. INR was designed and validated only for monitoring warfarin therapy, not for predicting bleeding risk in liver disease. 1, 2 The rebalanced hemostasis in cirrhosis means that standard coagulation tests do not reflect actual bleeding risk. 1
What You Should Do Instead
Proceed directly with paracentesis without any blood product transfusion. 1
Use ultrasound guidance if available to minimize complications. 1, 2
Choose the left lower quadrant (2 finger breadths cephalad and medial to the anterior superior iliac spine) as the puncture site. 1, 5
Avoid the inferior epigastric arteries and visible collateral vessels. 1, 5
If removing >5 liters of ascites, administer albumin 8 g per liter removed after the procedure to prevent post-paracentesis circulatory dysfunction. 1