Pt is 58 yo M with PMH of alcoholism, HCV with liver cirrhosis (h/o variceal GI bleeds, h/o SBP, h/o hepatic encephalopathy) presents to ED with 2-3 days of altered mental status and fever, you want to rule-out Spontaneous Bacterial Peritonitis and you send your newly minted intern over to get set up for a paracentesis and before you know-it, the intern is back, smiling brightly, with a vial of presumed ascitic fluid, although looking pretty bloody.
You do a quick check to make sure the patient is not hemorrhaging in the hall and then you get a call from the lab reporting a panic value of an INR of 2.2. How do you correct for a bloody paracentesis to get an accurate PMN count in order to diagnose SBP? Was there any contraindication to doing paracentesis in a person with INR 2.2?
Correction for a bloody tap:
The accepted correction is for every 250/mm3 RBC, correct 1 PMN . Still applying the cutoff of 250/mm3 PMN cutoff for diagnosis of SBP.
This correction is based on the maximum expected ratio of PMN to RBC normally present in peripheral blood [1,2]
Safe to tap with elevated INR:
A prospective study of 1100 large-volume paracenteses documented no bleeding complications with no pre- or post-procedure transfusions required despite INRs as high as 8.7 and platelet counts as low 19,000/mL, only 12 of which used ultrasound guidance [3].
Another study of chart review of 4,729 paracentesis procedures revealed bleeding was not related to operator experience, elevated international normalized ratio or low platelets. [4]
Another paper overall reduction in bleeding complications with addition of ultrasound (however, excluded patients with increased bleeding chances pre-procedure), looking at 69,859 paracentesis patient records, 45% of these procedures were ultrasound guided. Of those getting paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). [5]
1. BA Runyon. Ascites and spontaneous bacterial peritonitis M Feldman, BF Scharschmidt, MH Sleisenger (Eds.), Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. Pathophysiology/Diagnosis/Management, 6th ed, vol 2, W.B. Saunders Co, Philadelphia (1998), pp. 1310–1313
2. JC Hoefs. Increase in ascites WBC and protein concentrationsduring diuresis in patients with chronic liver disease
Hepatology, 1 (1981), p. 249
3. Grabau CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, Kamath PS. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004 Aug;40(2):484-8
4. Pache I. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther. 2005 Mar 1;21(5):525-9.
5. Mercaldi CJ, Lanes SF.Ultrasound Guidance Decreases Complications And Improves The Cost Of Care Among Patients Undergoing Thoracentesis And Paracentesis. Chest. 2013;143(2):532-538.
