CARI bx guidelines 2019

Pre bx

• Risk for bleeding hb <80 but not recommended to transfuse
• Control BP <140 sys, no evidence (not in CARI, just my own feeling)
• Ensure plts <50 and INR <1.5

Drugs

• Continue Aspirin if high risk
  • Within 3 months of bare metal or 12 months of drug eluting stent
  • Symptomatic myocardial ischemia
  • PVD (including PV stent)
  • Previous ischaemic stroke
• Stop Aspirin if low risk for 3 days to prevent major bleeding, 7 to prevent minor
• Stop ADP (clopidogrel / prasugrel) 5-7 days prior
• Warfarin 5 days
• DOAC (dabigatran, rivaroxaban, apixaban) 48-72 hours pre
• Heparin 4-6 hours
• LMWH 24 hours

CARI suggest bridging in high VTE risk

• Mechanical mitral valve
• Mechanical aortic + additional risk factors
• APS
• Embolic event in last 3 months
• AF with CHADS2VASC 5 or 6 + previous thromboembolic event

Wait 24-48 hours before restarting anything

Desmopressin

• 0.3ug/kg IV 30 mins pre bx. No evidence either way.
• If it has any role it would be in advanced CKD, uraemic patients.
• If given, avoid excessive fluids obviously ( 6-8 hours)
• Hypothetical risk of thrombosis = avoid in severe CV disease/vascular stent

Proceedure

• 16 G needle, consider throw distance if possible
• USS always, CT if tricky
• Super aneterolateral position for obese / resp difficulty
• Prone with pillow under abdo to splint kidneys for natives
• Supine for tx

Post bx

• 6-24 hours observation
• Low risk patients 6-8 hours and same day discharge
• Admit the higher risks for 24 hrs
  • Advanced CKD
  • AKI
  • HTN
  • >70 years old
  • Anticoagulation issues

Regular obs, check urine frequently

No heavy physical activity for 1-2 weeks

Bleeding

• IV fluid resuscitation
• CT angio
• If prolonged urinary tract bleeding or post bx HTN screen for AVF (CT or US) – interventional radiology for initial management
• Surgical team if radiologically failing