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Procedure Specific Guidelines

Procedure Specific Guidelines and Contraindications:

  • Thoracentesis
  • Relative Contraindications:
  • INR > 2-3, N/A for patients with cirrhosis
  • Platelets < 20K
  • < 1 cm depth of fluid
  • All simple, moderate-large effusions that have not been proven to be malignant should be tapped by MPS. If these criteria are not met or if the patient is on a DOAC or antiplatelet, the MPS attending should discuss directly with interventional pulmonology.

  • Follow up labs in a timely manner and remember to follow up cytology if sent. Pleural effusions that are exudative, malignant, re-accumulate quickly, or appear complicated/loculated should be referred to IP.

  • Paracentesis

  • Contraindications:
  • DIC and hyper-fibrinolysis are the only contraindications to procedure
  • No need to check labs or correct coagulopathy or thrombocytopenia in most cases -- 2004 retrospective study with 1100 paracentesis, INR 0.9-8.7, Plt 19k-300k. No bleeding complications. (Grabau, 2004)
  • Consider DDAVP for uremic patients.

  • Replace 8 gm / L of 25% albumin for removal of > 5 L of ascites. For patients with AKI, hepatology may request albumin administration for smaller volumes.

  • Lumbar Puncture

  • Contraindications: Note this is the highest risk procedure the MPS performs in terms of bleeding risk. Also note that the platelet threshold has been lowered to 30K and that antiplatelets are no longer a contraindication as of 2025.
  • INR > 2
  • PLT < 30K
  • DOAC
  • Increased intracranial pressure
  • Suspected spinal epidural abscess
  • Consider head imaging if the patient is > 60 years old, immunocompromised, has had a seizure within one week of presentation, has an abnormal level of consciousness, or an abnormal neurologic exam (including papilledema).
  • Requests for IT chemo (both inpatient and outpatient) should be discussed with MPS at least 24 hours in advance.

  • For outpatient chemo, ask the charge or bedside RN to page when the patient’s platelets are > 30K, the chemo and kit is at bedside, and pre-med (if needed) is ready.

  • Central Venous Catheterization, including hemodialysis lines

  • Relative contraindications: Note that this is frequently an emergent procedure in critically ill patients and benefits >> risk. Consider most experienced operator to perform high risk lines.
  • INR > 2-3
  • PLT < 20K
  • Page CVAD liaison to assist with witnessing consent, positioning and shaving patient if needed, capturing ultrasound image, and appropriately dressing line (especially bleeding lines).
  • At UNC, manometry and imaging of the guidewire in the IJ is required before dilation.
  • Note that at the time of this update, the Bard trialysis catheters do not come in fully supplied kits. They are missing a probe cover, manometry tubing, and CHG dressing. Data on their CLABSI rates is being collected.

Medicine Procedure Service

Guidelines for Peri-procedural Management of Bleeding Risk

Low Bleeding Risk Low Bleeding Risk (w/caveats) Low-Moderate Bleeding Risk
Paracentesis Thoracentesis Lumbar puncture*
CVC
INR <2-3, N/a for cirrhosis <2-3 <2
Platelet >20 >20 >30
ASA, low dose Hold not required Hold not required Hold not required
ASA, high dose Hold not required Hold not required Hold not required
Clopidogrel Hold not required Discuss with IP Hold not required. Consider on a case-by-case basis
Ticagrelor Hold not required Discuss with IP Hold not required. Consider on a case-by-case basis
Prasugrel Hold not required Discuss with IP Hold not required. Consider on a case-by-case basis
UFH (5000 units TID prophy) Hold not required Hold not required Hold not required
UFH (therapeutic) Hold not required Hold if safe Stop 6 hours before
UFH (therapeutic) Hold not required or discuss with IP Consider sending PTT if supratherapeutic.
UFH (therapeutic) Hold not required (PTT should be < 45 sec)
LMWH (q24 h prophy) Hold not required Hold not required Stop 12 hours before (GFR > 30)
LMWH (q24 h prophy) Hold not required Stop 24 hours before (GFR <30)
LMWH (therapeutic) Hold not required Hold if safe Stop 24 hours before (GFR > 30)
LMWH (therapeutic) Hold not required or discuss with IP Stop 48 hours before (GFR <30)
Warfarin INR < 3 Discuss with IP Stop until INR < 1.8
Apixaban (Eliquis), BID Hold not required Discuss with IP Hold 4 doses (GFR > 50) or 6 doses (GFR <30-50)
Dabigatran (Pradaxa), BID Hold not required Discuss with IP Hold 4 doses (GFR > 50) or 6-8 doses (GFR < 30-50)
Rivaroxaban (Xarelto), daily Hold not required Discuss with IP Hold for 2 doses (GFR > 30) or 3 doses (GFR < 30)
  • *2019 SIR guidelines now consider LP to be a low-risk procedure, was a moderate risk procedure in the 2012 guidelines. MD Anderson 2022 guidelines is more conservative. This chart reflects an attempt with alignment with UNC neuroradiology, SIR, MD Anderson, and prior guidance from UNC hematology.
  • Do not check labs for routine paracentesis
  • For urgent procedures, consider heme consult for reversal agents
  • Consider pharmacy consult for clearance of DOACs, especially in patients with renal insufficiency
  • Adapted from the 2019 Society of Interventional Radiology Consensus Guidelines: https://www.jvir.org/article/S1051-0443(19)30407-5/pdf and MD Anderson 2022 guidelines: https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-peri-procedure-anticoagulants-web-algorithm.pdf