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 for thoracentesis 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.
- 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]
- 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
What are the anticoagulation guidelines for thoracentesis?
Several society guidelines recommend holding antiplatelet medications and anticoagulants prior to thoracentesis. Clinical practice guidelines also recommend correcting international normalized ratios of more than two and platelet counts <50 X10∧9/L in accordance with thoracentesis anticoagulation guidelines.
Is anticoagulation after chest tube placement the same for thoracentesis?
Anticoagulation management following chest tube placement and thoracentesis can differ based on the clinical context. Chest tube placement usually does not preclude anticoagulation continuation, with adjustments made on a case-by-case basis, while anticoagulation therapy after thoracentesis is subject to individual patient factors, indication, and bleeding risk, necessitating careful evaluation and potential temporary adjustments. Patient-specific medical history and procedure indications should guide these decisions, and close monitoring for complications remains essential. Consulting a healthcare professional for personalized guidance is advisable.
Thoracentesis vs Chest Tube. When to use each?
The choice between thoracentesis and chest tube placement depends on the specific clinical situation, the volume of fluid or air in the pleural space, and the intended goals of the procedure.
Thoracentesis is typically employed for smaller to moderate pleural effusions, primarily for diagnostic sampling or symptomatic relief, as it’s less invasive, involving the removal of a limited amount of pleural fluid using a needle or catheter. In contrast, chest tube placement is reserved for larger effusions, pneumothorax, hemothorax, or situations requiring ongoing drainage and lung re-expansion, as it’s a more invasive procedure involving the insertion of a larger tube into the pleural space. The choice depends on the effusion’s size and clinical context, with thoracentesis for less severe cases and chest tube placement for more extensive effusions or specific conditions that necessitate continuous drainage.
Thoracentesis vs Thoracostomy. When to use each?
A thoracentesis is a procedure that drains fluid or air from your chest. A thoracostomy is a procedure providers use to insert a chest tube (which drains fluid or air from your chest over a few days). Thoracentesis is typically performed to remove a small amount of pleural fluid or to sample it for diagnostic purposes, especially when there is suspicion of infection, inflammation, or cancer. On the other hand, thoracostomy, also known as chest tube insertion, involves placing a tube into the pleural space to drain larger amounts of fluid (e.g., for pleural effusions) or to relieve pressure caused by conditions like a pneumothorax (collapsed lung).