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.
- 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