Safety of Thoracentesis and Tube Thoracostomy in Patients with Uncorrected Coagulopathies

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 safely without the need for pre-procedure blood products at a much lower threshold. Most recently the 2019 Society of Interventional Radiology guidelines have stated that low bleeding risk procedures such as thoracentesis, paracentesis, non-tunneled chest tube insertion and ultrasound-guided central line placement can all be performed if platelets are 20,000/µL or more and INR of 3 or less. They also mention that these procedures can be performed without reversal for patients “on antiplatelets and direct oral anti-coagulants should not be withheld and that for patients on warfarin, an INR of ≤3 is sufficient.”

Now, a new meta-analysis and systematic review has been published in Chest that analyzed 18 studies and over 5,100 patients with uncorrected coagulopathies who underwent either ultrasound-guided thoracentesis or chest tube placement. Image-guidance for thoracentesis is important because we know the incidence of major bleeding is decreased by 40% over landmark-guided thoracentesis. The authors found that pooled rate of combined major bleeding or mortality was <1%.

This meta-analysis and systematic review came to the same conclusion as the Society of Interventional Radiology that ultrasound-guided thoracentesis or non-tunneled chest tube placement can be safely performed in patients who have platelets at least 20,000/µL, have an INR <3 on warfarin or who are on DOAC anticoagulation or antiplatelets.



  1. Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations. Journal of Vascular and Interventional Radiology 2019;30(8):1168-84. doi: 10.1016/j.jvir.2019.04.017 [published Online First: Jun 20]
  1. Fong C. et al. Safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy: a systematic review and meta-analysis. Chest. 2021 Apr 24; S0012-3692(21)00761-3




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