Douglas Robert Kitchin MD, Presenter: Nothing to Disclose

Lucas Ludeman MD, Abstract Co-Author: Nothing to Disclose

J. Louis Hinshaw MD, Abstract Co-Author: Stockholder, NeuWave Medical, Inc Medical Advisory Board, NeuWave Medical, Inc Stockholder, Novelos Therapeutics, Inc

Current guidelines suggest INR<1.5 and platelets>50,000/uL prior to undergoing percutaneous liver biopsy. The purpose of this study is to determine if changing these parameters to INR<2.0 and platelets>25,000/uL results in less utilization of preprocedural FFP and platelet transfusion while maintaining a low hemorrhagic complication rate.


Our department relaxed coagulation guidelines for percutaneous liver biopsies in April 2009 to INR< 2.0 and platelets >25,000/uL. 969 consecutive ultrasound guided percutaneous liver biopsies were performed from January 2007 to August 2011, 377 under the stricter and 592 under the more lax guidelines.  These were retrospectively reviewed and preprocedural INR and platelet levels, preprocedural FFP or platelet administration, and hemorrhagic complications were recorded.


There was no significant difference in the laboratory profiles of the patients biopsied before guideline relaxation from those after (INR 1.08 ± 0.18, plts 213K ± 94K before; INR 1.07 ± 0.18, plts 221K ± 94K after), nor was there a change in hemorrhagic complication rate (1.9% vs 1.9%) or preprocedural platelet administration (0.8% before, 0.3% after;p=0.38). However, there was a significant decrease in preprocedural FFP administration (4.2% before vs 1.0% after;p=0.0015). When categorizing patients on the basis of INR and platelet level alone, there was a significant increase in hemorrhagic complications in patients with INR>1.5 (12% vs 1.9%; p=0.003) and platelets< 25,000/uL (13.3%  vs 1.9%; p=0.008). However, patients with INR levels initially greater than 1.5 who received FFP and were corrected (INR 1.46 ± 0.07) had a similar hemorrhagic complication rate (11.1%) as those whose INR levels were not corrected (INR 1.9 ± 0.33, 15.4%).

Based upon a review of the literature, we changed our coagulation guidelines for percutaneous liver biopsy to INR<2.0 and platelets>25,000/uL, which has resulted in decreased FFP transfusion while maintaining a low complication rate, and has had a positive impact on our overall workflow.  Patients with INR>1.5 and platelets <25,000/uL are at elevated risk of hemorrhagic complications, but correcting the INR with FFP does not mitigate that risk.  

More relaxed coagulation guidelines result in decreased FFP administration and, while patients with INR>1.5 and platelets<25,000/uL are at elevated risk, FFP transfusion does not mitigate that risk.

Kitchin, D, Ludeman, L, Hinshaw, J, Coagulation Profiles: Can We Safely Relax the INR and Platelet Parameters for Image-guided Percutaneous Liver Biopsy?.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13020759.html