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Is Thoracentesis Safe in Coagulopathic Patients?

June 10, 2021

Written by Clay Smith

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There is a very low, perhaps 0% bleeding and mortality risk, in performing thoracentesis or tube thoracostomy on patients taking antiplatelet or anticoagulant agents or those with thrombocytopenia or coagulopathy from a disease process, like cirrhosis.

Why does this matter?
Anecdote is powerful. I was on shift when my partner had a bad bleeding outcome after a thoracentesis was done in a patient taking warfarin. Since then, I have not done this procedure on such patients despite several studies indicating it is safe. Maybe this will change my mind.

Overcoming anecdote
This was a systematic review and meta-analysis of 18 studies, with 5,134 patients undergoing thoracentesis or tube thoracostomy (chest tube) with some form of coagulopathy, such as that caused by an underlying disease (thrombocytopenia, cirrhosis, etc.) or drug (antiplatelet or anticoagulant). When including all 18 studies, or excluding 6 articles that were in abstract form only, both analyses found the overall rate of bleeding and mortality was 0% (95%CI 0%-1%; 0%-2%, respectively). Also, in all subgroups – drug related risk only (such as aspirin, clopidogrel, both, or an anticoagulant), thrombocytopenic risk only, elevated INR risk only, tube thoracostomy only, thoracentesis only, retrospective studies only, prospective studies only – the major bleeding rate remained 0%. In many of these studies, the INR wasn’t excessively high; the highest was in one smaller study, where the average INR was 2.3. My take home is that in patients taking antiplatelet agents, on usual dose anticoagulation, or with mild coagulopathy from disease, I can think of thoracentesis the way I currently think of paracentesis – namely, it’s safe to do. I am still wary of performing procedures on the chest in patients with marked thrombocytopenia or very high INR – but this is my own clinical judgment and you may come to a different conclusion.

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. doi: 10.1016/j.chest.2021.04.036. Online ahead of print.

What are your thoughts?