Proposed Clinical Practice Guidance for Large-Volume Abdominal and Pleural Paracentesis with Emphasis on Coagulopathy Management

Abstract

Background: Large-volume paracentesis (LVP) of the peritoneal and pleural cavities is a common diagnostic and therapeutic intervention in patients with liver cirrhosis or advanced heart failure, which are both frequently associated with ascites or pleural effusion. Although generally regarded as a low-risk procedure, LVP may lead to complications such as intrapleural or intra-abdominal hemorrhage, and more commonly abdominal wall bleeding, as well as organ puncture and infection. Performing LVP in patients with coagulopathy or bleeding disorders, whether disease-related or due to anticoagulant therapy, poses a significant clinical challenge. The safety thresholds for such procedures remain inconsistent, and strategies to mitigate bleeding risk are still debated among professional societies. Methods: This review integrates institutional experience with a systematic synthesis of the current international literature to identify the safest and most effective approaches for performing LVP in patients with coagulopathy. The methodological framework included a comparative analysis of existing professional guidelines, as well as a critical evaluation of published evidence regarding risk stratification, pre-procedural correction strategies, and peri-procedural management. The evidence grading was assessed with the STAIR checklist. Results: Analysis of the evidence revealed substantial variability among professional recommendations concerning acceptable platelet and INR thresholds, as well as differing approaches to the management of patients receiving anticoagulant or antiplatelet therapy. Despite these discrepancies, the aggregated data support the conclusion that LVP can be performed safely in most patients with mild-to-moderate coagulopathy, provided that appropriate risk assessment and technical precautions are implemented. Conclusions: The resulting evidence-informed suggestions provide a practical framework for clinicians performing LVP in high-risk patients. By emphasizing systematic pre-procedural evaluation, individualized management of coagulopathy, and adherence to standardized procedural techniques, this work aims to promote safety, consistency, and confidence in the performance of large-volume paracentesis across diverse clinical settings.

Keywords: ascites; coagulation management; large-volume paracentesis; pleural effusion; ultrasound guidance.

Figure 1

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Algorithm for pre-procedure management of coagulopathy. Plt, platelets; INR, international normalized ratio; FFP, fresh frozen plasma; PCC, prothrombin complex concentrate; LMWH, low-molecular-weight heparin.