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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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2
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Wang TF, Sanfilippo KM, Douketis J, Falanga A, Karageorgiou J, Maraveyas A, Ortel TL, Soff G, Vedantham S, Zwicker JI. Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH. J Thromb Haemost 2022; 20:3026-3038. [PMID: 36217296 DOI: 10.1111/jth.15896] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/31/2022] [Accepted: 09/23/2022] [Indexed: 01/13/2023]
Abstract
Patients with cancer have an increased risk of thrombosis requiring anticoagulants and/or antiplatelet agents, and they can also encounter thrombocytopenia due to cancer itself or cancer therapies. They often undergo many procedures such as tissue or bone marrow biopsies, placement of central access lines, diagnostic or therapeutic draining procedures, lumbar puncture, and more. Management of antithrombotic agents or thrombocytopenia around the time of these procedures is highly variable. In this document, the Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kristen M Sanfilippo
- Division of Hematology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anna Falanga
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - John Karageorgiou
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Pathology, Duke University, Durham, North Carolina, USA
| | - Gerald Soff
- Division of Hematology, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Jeffrey I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.
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Affiliation(s)
- Christopher M Kapp
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, 840 South Wood Street, Room 920-N, Chicago, IL 60612, USA.
| | - Hans J Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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4
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Godfrey M, Puchalski J. Pleural Effusions in the Critically Ill and "At-Bleeding-Risk" Population. Clin Chest Med 2021; 42:677-686. [PMID: 34774174 DOI: 10.1016/j.ccm.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Thoracentesis is a common bedside procedure, which has a low risk of complications when performed with thoracic ultrasound and by experienced operators. In critically ill or mechanically ventilated patients, or in patients with bleeding risks due to medications or other coagulopathies, the complication rate remains low. Drainage of pleural effusion in the intensive care unit has diagnostic and therapeutic utility, and perceived bleeding risks should be one part of an individualized and comprehensive risk-benefit analysis.
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Affiliation(s)
- Mark Godfrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 15 York Street, LCI 100, New Haven, CT 06510, USA
| | - Jonathan Puchalski
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 15 York Street, LCI 100, New Haven, CT 06510, USA.
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5
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Fong C, Chang Tan CW, Yan Tan DK, See KC. Safety of Thoracentesis and Tube Thoracostomy in Patients With Uncorrected Coagulopathy: A Systematic Review and Meta-analysis. Chest 2021; 160:1875-1889. [PMID: 33905681 DOI: 10.1016/j.chest.2021.04.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/04/2021] [Accepted: 04/17/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Thoracentesis and tube thoracostomy are common procedures with bleeding risks, but existing guidelines may be overly conservative. We reviewed the evidence on the safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy. RESEARCH QUESTION Is it safe to perform thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy? STUDY DESIGN AND METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. PubMed and Embase were searched from inception through December 31, 2019. Included studies involved patients with uncorrected coagulopathy because of disease (eg, thrombocytopenia, liver cirrhosis, kidney failure) or drugs (eg, antiplatelets, anticoagulants). Relevant outcomes were major bleeding and mortality. RESULTS Eighteen studies (5,134 procedures) were included. Using random-effects meta-analysis, the pooled major bleeding and mortality rate was 0 (95% CI, 0%-1%). No publication bias was found. Excluding six studies that were in abstract form, meta-analysis of the remaining 12 full articles showed that the pooled major bleeding and mortality rate also was 0 (95% CI, 0%-2%). Subgroup analysis performed for patients with uncorrected coagulopathy resulting from disease or drugs showed similar results. INTERPRETATION Among patients with uncorrected coagulopathy who underwent thoracentesis or tube thoracostomy, major bleeding and mortality complications were uncommon. Our results suggest that in appropriately selected patients, thoracentesis or tube thoracostomy can be performed safely. TRIAL REGISTRY PROSPERO; No.: CRD42020152226; URL: www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Clare Fong
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University of Singapore, Singapore, Republic of Singapore.
| | - Colin Wei Chang Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Drusilla Kai Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University of Singapore, Singapore, Republic of Singapore; Department of Medicine, National University of Singapore, Singapore, Republic of Singapore
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Pagliuca S, Bailly C, Talbot A, Bertinchamp R, Peyrony O, Elezi A, Bourrier P, Lengline E. Point-of-care ultrasound with handheld devices in hematology: a monocentric single-stage phase II study. Leuk Lymphoma 2021; 62:1379-1385. [PMID: 33416408 DOI: 10.1080/10428194.2020.1869958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Point of care ultrasound (PoCUS) with pocket-size devices is an efficient and safe imaging modality that became a standard of care in various clinical settings. However, its implementation in hematology has never been evaluated so far. We conducted a prospective monocentric study aiming to harvest data on its usage and to assess its diagnostic and interventional performance in improving the accuracy of basic physical examination in hematological patients. After a focused training program, six hematologists were trained and conducted this study. Sixty-two patients were included. Only in 19 cases, further specialized imaging was required, whereas, in 43 patients PoCUS was sufficient to address the clinical inquiries. The use of PoCUS devices was assessed for its performance difficulty and usefulness perception with satisfactory outcomes. This study represents a proof-of-concept application of PoCUS in hematology, suggesting benefits over the physical examination.KEY POINTSPoCUS is particularly attractive in a hematological setting because able to improve the accuracy of physical examination.A hematology-focused training in PoCUS using handheld devices can allow hematologists to perform bed-side diagnostic and interventional US-based exams.
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Affiliation(s)
- Simona Pagliuca
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France.,Emergency Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Cecile Bailly
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France
| | - Alexis Talbot
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France
| | - Rémi Bertinchamp
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France
| | - Olivier Peyrony
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France.,Emergency Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Arben Elezi
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France.,Emergency Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Pierre Bourrier
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France.,Radiology Department, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Etienne Lengline
- Hematology Department, Saint-Louis University Hospital, University of Paris, AP-HP, Paris, France
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Singh K, Balthazar P, Duszak R, Horný M, Hanna TN. Clinical Yield of Routine Chest Radiography after Ultrasound-Guided Thoracentesis. Acad Radiol 2020; 27:1379-1384. [PMID: 31831265 DOI: 10.1016/j.acra.2019.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis. MATERIALS AND METHODS All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed. RESULTS Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath. CONCLUSION Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography.
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Affiliation(s)
- Kush Singh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Patricia Balthazar
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States; Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA 30322, United States
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
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Cavanna L, Citterio C, Nunzio Camilla D, Orlandi E, Toscani I, Ambroggi M. Central venous catheterization in cancer patients with severe thrombocytopenia: Ultrasound-guide improves safety avoiding prophylactic platelet transfusion. Mol Clin Oncol 2020; 12:435-439. [PMID: 32257200 PMCID: PMC7087476 DOI: 10.3892/mco.2020.2010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 06/18/2019] [Indexed: 01/13/2023] Open
Abstract
Prior research has revealed that ultrasound (US) guided central venous catheterization (CVC) is associated with a reduction in the complication rate such as pneumothorax and an improved first-pass success placing CVC in the internal jugular vein. The present study investigated if US-guided CVC, in a subset of cancer patients with severe thrombocytopenia, reduced bleeding risk and avoided prophylactic platelet transfusion. The efficacy and safety of US-guided CVC placement in cancer patients with severe thrombocytopenia was retrospectively analyzed over a period of 9 years (Dec 2000-Jan 2009), 1,660 and 207 patients with cancer underwent US-guided CVC placement into internal jugular vein respectively at the Department of Onco-Haematology, Hospital of Piacenza. The first group of patients included patients in active antitumor treatment, while the second group included patients in the palliative phase. A total of 110 (5.89%) of these 1,867 patients exhibited severe thrombocytopenia defined as platelet count ≤20x109/l, and formed the basis of this study. All procedures were evaluated for bleeding complications as defined by the National Institute of Health Common Terminology Criteria for Adverse Events (CTCAE 3.0). In the subgroup of the 110 patients with severe thrombocytopenia a single needle puncture of the vein was employed in 121 of the 122 procedures (99.18%) and no attempt failures were registered. No pneumothorax, no major bleeding and no nerve and arterial puncture were reported, only one self-limiting hematoma (0.90%) at the site of CVC insertion was reported (CTCAE 3.0 grade 1). No platelet transfusions were performed in the 110 patients, pre and post CVC placement. We believe that US-guided CVC insertion procedures into the internal jugular vein makes the difference in safety, also in thrombocytopenic patients avoiding prophylactic or post procedure platelet transfusion.
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Affiliation(s)
- Luigi Cavanna
- Department of Onco-Haematology, Hospital Guglielmo da Saliceto, I-29121 Piacenza, Italy
| | - Chiara Citterio
- Department of Onco-Haematology, Hospital Guglielmo da Saliceto, I-29121 Piacenza, Italy
| | - Di Nunzio Camilla
- Department of Onco-Haematology, Hospital Guglielmo da Saliceto, I-29121 Piacenza, Italy
| | - Elena Orlandi
- Department of Onco-Haematology, Hospital Guglielmo da Saliceto, I-29121 Piacenza, Italy
| | - Ilaria Toscani
- Department of Onco-Haematology, Hospital Guglielmo da Saliceto, I-29121 Piacenza, Italy
| | - Massimo Ambroggi
- Department of Onco-Haematology, Hospital Guglielmo da Saliceto, I-29121 Piacenza, Italy
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Patel IJ, Rahim S, Davidson JC, Hanks SE, Tam AL, Walker TG, Wilkins LR, Sarode R, Weinberg I. 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. J Vasc Interv Radiol 2019; 30:1168-1184.e1. [DOI: 10.1016/j.jvir.2019.04.017] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
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