Periprocedural Bleeding Risk for Thrombocytopenia, Coagulopathy, Antiplatelets and Anticoagulation

Joseph Esherick, M.D., FAAFP, FHM
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This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows: Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor…
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Safety of Thoracentesis and Tube Thoracostomy in Patients with Uncorrected Coagulopathies

Tube Thoracostomy Insertion
Joseph Esherick, M.D., FAAFP, FHM
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Traditionally, it was felt that the INR had to be less than 1.5 and platelets had to be at least 50,000/µL to perform most bedside procedures. With more clinical evidence, we now know that low-risk bedside procedures can be performed…
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Incidence of Spinal Hematoma from Lumbar Punctures in Patients with a Coagulopathy or Thrombocytopenia

Lumbar Puncture CME
Joseph Esherick, M.D., FAAFP, FHM
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A recent cohort study using the Danish nationwide medical registry demonstrates that the incidence of a spinal or epidural hematoma from lumbar punctures in patients with pre-existing thrombocytopenia (Platelets<150 K) or coagulopathy (INR>1.4 or aPTT>39 seconds) is not significantly higher…
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Risk of Epidural Hematoma from Lumbar Puncture in Patients with a Coagulopathy

Joseph Esherick, M.D., FAAFP, FHM
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Class 1 evidence to inform decisions about the safety of lumbar punctures in patients with a coagulopathy are lacking. The only guidance we have regarding the safety of lumbar punctures is based on clinical guidance from organizations such as the…
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Guidelines for Antiplatelet and Anticoagulation Discontinuation before a Lumbar Puncture

Joseph Esherick, M.D., FAAFP, FHM
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This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesia (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.  The following table…
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Bleeding Risk of Central Line Insertion in Coagulopathic Patients

Joseph Esherick, M.D., FAAFP, FHM
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The evidence base for the safety of ultrasound-guided central line placement with thrombocytopenia or in patients with a bleeding diathesis is not robust.  Nevertheless, based on the data available most procedural experts feels that an ultrasound-guided central venous catheter insertion…
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Performing Procedures on Patients Who Take Dabigatran, Rivaroxaban, and Apixaban

Joseph Esherick, M.D., FAAFP, FHM
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Over the past several years, there has been a dramatic increase in the use of the new oral anticoagulants (Dabigatran, Rivaroxaban, and Apixaban).  The popularity of these medications stems not only from aggressive pharmaceutical monitoring to physicians and to the…
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Safety of Lumbar Puncture in Adults and Children with Thrombocytopenia

Joseph Esherick, M.D., FAAFP, FHM
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Traditionally, it has been promulgated by anesthesiologists that you need a platelet count of 100,000 to safely perform neuraxial regional anesthesia (spinal and epidural anesthesia).  This practice pattern has continued even though Children’s Hospitals routinely perform intrathecal injections for prophylactic chemotherapy with…
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Safety of Thoracentesis with Coagulopathy or Thrombocytopenia

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
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Historically, it was felt that a platelet count below 50,000 or an INR>1.5 was a contraindication to thoracentesis because of an increased bleeding risk.  These were arbitrary cut-offs that have since been challenged with newer kits and the use of…
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Anticoagulation is Likely Beneficial for Portal Vein Thrombosis in Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
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The optimal treatment of portal vein thrombosis in patients with cirrhosis has been a topic of debate for quite some time.  To this date there have been no large prospective, randomized controlled trials to help guide management in these patients. …
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Safe Ways to Rule Out Pulmonary Embolism without Using a CT Pulmonary Angiogram

Joseph Esherick, M.D., FAAFP, FHM
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Pulmonary embolism (PE) is one of the most difficult to diagnose and potentially fatal disorders in medicine.  Because of this, CT pulmonary angiograms (CTPA) are over utilized so as to not miss this potentially fatal problem.  There are three ways…
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A Low Peripheral Neutrophil-Lymphocyte Ratio Can Help to Exclude a Subarachnoid Hemorrhage

Joseph Esherick, M.D., FAAFP, FHM
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An elevated peripheral neutrophil-lymphocyte ratio is an indicator of inflammation. Investigators from a Turkish university hospital hypothesized that this ratio might differ in patients with subarachnoid hemorrhage (SAH) versus those with other headache syndromes. They performed a retrospective study of…
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Misdiagnosed Cellulitis Increases Unnecessary Hospital Admissions and Antibiotic Use

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Dermatology, Gastrointestinal diseases, Hematology, Infections, medical procedures
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There are multiple noninfectious medical disorders that mimic cellulits.  In this retrospective study, researchers focused on misdiagnosis of cellulitis in 259 patients hospitalized with presumed diagnoses of lower extremity cellulitis at a Boston teaching hospital. Patients with complicating factors (e.g.,…
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When to Stop CPR for Out-of-Hospital Cardiac Arrest?

Joseph Esherick, M.D., FAAFP, FHM
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The Universal Termination of Resuscitation Guidelines suggest that resuscitation should be terminated if at least four rounds of CPR have occurred and the following three criteria are met: The arrest was NOT witnessed by emergency medical services (EMS) There has…
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Summary of Sepsis and Septic Shock Treatment in 2017

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Hematology, Infections, medical procedures, Respiratory diseases
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Definitions Presumed source with SIRS criteria = infection Infection with life-threatening organ dysfunction = sepsis Sepsis refractory to intravenous fluid challenge = septic shock Treatment of sepsis or septic shock Draw blood cultures x 2 Analyze any fluid that may…
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