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Abdominal Radiology

, Volume 43, Issue 6, pp 1494–1501 | Cite as

Percutaneous liver biopsy and revised coagulation guidelines: a 9-year experience

  • Douglas R. KitchinEmail author
  • Alejandro Munoz del Rio
  • Michael Woods
  • Lucas Ludeman
  • J. Louis Hinshaw
Article

Abstract

Purpose

To retrospectively review revised pre-procedural coagulation guidelines for percutaneous liver biopsy to determine whether their implementation is associated with increased hemorrhagic complications on a departmental scale. Secondary endpoints were to determine the effect of this change on pre-procedural blood product (FFP and platelet) utilization, to evaluate the impact of administered blood products on hemorrhagic complications, and to determine whether bleeding complications were related to INR and platelet levels.

Materials and methods

This IRB-approved, HIPAA-compliant, retrospective study reviewed 1846 percutaneous liver biopsies in 1740 patients, comparing biopsies performed, while SIR consensus pre-procedural coagulation guidelines were in place (INR ≤ 1.5, platelets ≥50,000 µL) to those performed after departmental implementation of revised, less stringent guidelines (INR ≤ 2.0, platelets ≥25,000 µL).

Results

On a departmental scale, there were significantly fewer hemorrhagic complications in the population of patients treated after adoption of less stringent guidelines as compared to those treated under the SIR guidelines (1.6% vs. 3.4%, p = 0.0192) despite a significant decrease in pre-procedural FFP (0.8% vs. 3.9%, p < 0.001) and platelet transfusions (0.3% vs. 1.2%, p = 0.021). Individual patient hemorrhagic complication rates significantly increased as INR increased (p = 0.006) and platelet counts decreased (p = 0.004), but pre-procedural FFP (p = 0.64) and/or platelet transfusion (p = 0.5) did not have a significant impact on hemorrhagic complication rates.

Conclusion

Implementation of less stringent pre-procedural coagulation parameter guidelines for percutaneous liver biopsy (INR ≤ 2.0, platelets ≥25,000 µL) did not result in an increase in departmental hemorrhagic complication rates but did significantly decrease pre-procedural FFP/platelet administration. An individual patient’s bleeding risk does increase as INR increases and platelets decrease, but pre-procedural FFP and/or platelet transfusion did not mitigate that increased risk.

Keywords

Liver Biopsy Pre-procedural Coagulation Guidelines 

Notes

Compliance with ethical standards

Conflicts of interest

J. Louis Hinshaw: Shareholder and Consultant for NeuWave Medical, a company which manufactures microwave ablation technology. Shareholder, Novleos, a company which manufactures tumor radiopharmaceuticals. All others—none.

References

  1. 1.
    Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD (2009) American Association for the Study of Liver D. Liver Biopsy Hepatol 49(3):1017–1044CrossRefGoogle Scholar
  2. 2.
    Gilmore IT, Burroughs A, Murray-Lyon IM, et al. (1995) Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London. Gut 36(3):437–441CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    McGill DB, Rakela J, Zinsmeister AR, Ott BJ (1990) A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology 99(5):1396–1400CrossRefPubMedGoogle Scholar
  4. 4.
    Piccinino F, Sagnelli E, Pasquale G, Giusti G (1986) Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol 2(2):165–173CrossRefPubMedGoogle Scholar
  5. 5.
    Minuk GY, Sutherland LR, Wiseman DA, MacDonald FR, Ding DL (1987) Prospective study of the incidence of ultrasound-detected intrahepatic and subcapsular hematomas in patients randomized to 6 or 24 hours of bed rest after percutaneous liver biopsy. Gastroenterology 92(2):290–293CrossRefPubMedGoogle Scholar
  6. 6.
    Caldwell SH (2001) Controlling pain in liver biopsy, or “we will probably need to repeat the biopsy in a year or two to assess the response”. Am J Gastroenterol 96(5):1327–1329PubMedGoogle Scholar
  7. 7.
    Patel IJ, Davidson JC, Nikolic B, et al. (2012) Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 23(6):727–736CrossRefPubMedGoogle Scholar
  8. 8.
    Dillon JF, Simpson KJ, Hayes PC (1994) Liver biopsy bleeding time: an unpredictable event. J Gastroenterol Hepatol 9(3):269–271CrossRefPubMedGoogle Scholar
  9. 9.
    Gazelle GS, Haaga JR, Rowland DY (1992) Effect of needle gauge, level of anticoagulation, and target organ on bleeding associated with aspiration biopsy. Work in progress. Radiology 183(2):509–513CrossRefPubMedGoogle Scholar
  10. 10.
    Ewe K (1981) Bleeding after liver biopsy does not correlate with indices of peripheral coagulation. Dig Dis Sci 26(5):388–393CrossRefPubMedGoogle Scholar
  11. 11.
    Terjung B, Lemnitzer I, Dumoulin FL, et al. (2003) Bleeding complications after percutaneous liver biopsy. An analysis of risk factors. Digestion 67(3):138–145CrossRefPubMedGoogle Scholar
  12. 12.
    Segal JB, Dzik WH, Transfusion Medicine/Hemostasis Clinical Trials N (2005) Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion 45(9):1413–1425CrossRefPubMedGoogle Scholar
  13. 13.
    Mahal AS, Knauer CM, Gregory PB (1981) Bleeding after liver biopsy. West J Med 134(1):11–14PubMedPubMedCentralGoogle Scholar
  14. 14.
    Holland L, Sarode R (2006) Should plasma be transfused prophylactically before invasive procedures? Curr Opin Hematol 13(6):447–451CrossRefPubMedGoogle Scholar
  15. 15.
    Gajic O, Dzik WH, Toy P (2006) Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med 34(5 Suppl):S170–S173CrossRefPubMedGoogle Scholar
  16. 16.
    Yang L, Stanworth S, Hopewell S, Doree C, Murphy M (2012) Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion 52(8):1673–1686 (quiz)CrossRefPubMedGoogle Scholar
  17. 17.
    Stanworth SJ, Brunskill SJ, Hyde CJ, McClelland DB, Murphy MF (2004) Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol 126(1):139–152CrossRefPubMedGoogle Scholar
  18. 18.
    O’Connor SD, Taylor AJ, Williams EC, Winter TC (2009) Coagulation concepts update. AJR Am J Roentgenol 193(6):1656–1664CrossRefPubMedGoogle Scholar
  19. 19.
    Institute NC (2009) Common Terminology Criteria for Adverse Events v4.0.Google Scholar
  20. 20.
    R Development Core Team (2013) R: a language and environment for statistical computing. R Foundation for Statistical Computing V, Austria. ISBN 3-900051-07-0. http://www.R-project.org.
  21. 21.
    McInnes MD, Kielar AZ, Macdonald DB (2011) Percutaneous image-guided biopsy of the spleen: systematic review and meta-analysis of the complication rate and diagnostic accuracy. Radiology 260(3):699–708CrossRefPubMedGoogle Scholar
  22. 22.
    Domen RE, Hoeltge GA (2003) Allergic transfusion reactions: an evaluation of 273 consecutive reactions. Arch Pathol Lab Med 127(3):316–320PubMedGoogle Scholar
  23. 23.
    Kleinman S, Caulfield T, Chan P, et al. (2004) Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion 44(12):1774–1789CrossRefPubMedGoogle Scholar
  24. 24.
    Popovsky MA, Moore SB (1985) Diagnostic and pathogenetic considerations in transfusion-related acute lung injury. Transfusion 25(6):573–577CrossRefPubMedGoogle Scholar
  25. 25.
    FDA (2010) Fatalities reported to FDA following blood collection and transfusionGoogle Scholar
  26. 26.
    Narick C, Triulzi DJ, Yazer MH (2012) Transfusion-associated circulatory overload after plasma transfusion. Transfusion 52(1):160–165CrossRefPubMedGoogle Scholar
  27. 27.
    Görlinger K, Saner F (2015) Prophylactic plasma and platelet transfusion in the critically Ill patient: just useless and expensive or even harmful? BMC Anesthesiol 15:86CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Douglas R. Kitchin
    • 1
    Email author
  • Alejandro Munoz del Rio
    • 2
  • Michael Woods
    • 2
  • Lucas Ludeman
    • 3
  • J. Louis Hinshaw
    • 2
  1. 1.Madison RadiologistsMadisonUSA
  2. 2.Department of RadiologyUniversity of Wisconsin-MadisonMadisonUSA
  3. 3.St. Paul RadiologySt. PaulUSA

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