Hi everyone, I am new here and very excited to become member of this great community.
I would like to hear your experiences in regards of what are your protocols to follow when you get bleeding after an us guided FNA (specially in liver) and if you have any “don’t sample” conditions or ultrasound findings where you prefer not to do it.
Hi everyone, I am new here and very excited to become member of this great community.
I would like to hear your experiences in regards of what are your protocols to follow when you get bleeding after an us guided FNA (specially in liver) and if you have any “don’t sample” conditions or ultrasound findings where you prefer not to do it. Have you ever consider going into surgery for this?
I was taught that if you suspect of bleeding you do compression in the site and monitor, I have had few of these cases but they have stopped quickly and I would like to get more information so I can be better prepared.
Thanks for any help
Comments
Welcome to the community Dr.
Welcome to the community Dr. Damian! If you are having bleeding issues on sampling, I know it sounds simple, but try using a lighter hand in a more direct and succinct approach through the body wall and then into the organ in and be sure to stick different spots in the organ each time kind of like he would with a lidocaine block. This ensures that your sampling new parenchyma each time and also gives you a better statistical sampling of the region. If you’re still getting bleeds then consider using a smaller gauge needle. I usually start with a 22-gauge but in more edematous organs or if considering mast cell disease I will go to a 25-gauge and I can always move up to a 22 if need be. The smaller needle gives you a smaller sample but it tends to be a higher quality one with left blood artifact.
I usually do aspirates on lipid dot at the liver is or what I’m suspecting to be lipidotic as this is a cellular pathology anyway but this opens up a whole discussion on what to sample and when the sample and have to sample at. The only time I’ve ever had any significant bleeding problems was when I did a Tru-Cut biopsy on a lipidotic liver or an organ with mast cell disease. Otherwise it’s just a matter of avoiding anechoic things that are color-flow positive 🙂 The other good rule of thumb is only stick what you are comfortable with and in more precarious scenarios get one good solid sample and get out of Dodge. I think a lot of the time bleeds occur when we go back in stick the same area that we just stuck and the samples will be less diagnostic anyway. If a liver for example looks like a chronic active hepatitis in which fibrosis is an issue I will use a larger Tru-Cut because these do not tend to bleed because they’re basically a scar with liver tissue in it. Whereas a hypoechoic liver that could be mast cell I will use a smaller gauge needle or do aspirates first and see how the tissue behaves and then do a Tru-Cut if necessary. I never Tru-Cut passive congestion levers because the liver is not the problem and those cases anyway because all they do is bleed because it’s like doing a Tru-Cut on a full sponge.
In the future we will be doing downloadable power points on many different subjects in internal medicine and will have CE credits attached in quiz format. This is one of the power points I intend on doing.
To help this helps and again welcome to the community
Welcome to the community Dr.
Welcome to the community Dr. Damian! If you are having bleeding issues on sampling, I know it sounds simple, but try using a lighter hand in a more direct and succinct approach through the body wall and then into the organ in and be sure to stick different spots in the organ each time kind of like he would with a lidocaine block. This ensures that your sampling new parenchyma each time and also gives you a better statistical sampling of the region. If you’re still getting bleeds then consider using a smaller gauge needle. I usually start with a 22-gauge but in more edematous organs or if considering mast cell disease I will go to a 25-gauge and I can always move up to a 22 if need be. The smaller needle gives you a smaller sample but it tends to be a higher quality one with left blood artifact.
I usually do aspirates on lipid dot at the liver is or what I’m suspecting to be lipidotic as this is a cellular pathology anyway but this opens up a whole discussion on what to sample and when the sample and have to sample at. The only time I’ve ever had any significant bleeding problems was when I did a Tru-Cut biopsy on a lipidotic liver or an organ with mast cell disease. Otherwise it’s just a matter of avoiding anechoic things that are color-flow positive 🙂 The other good rule of thumb is only stick what you are comfortable with and in more precarious scenarios get one good solid sample and get out of Dodge. I think a lot of the time bleeds occur when we go back in stick the same area that we just stuck and the samples will be less diagnostic anyway. If a liver for example looks like a chronic active hepatitis in which fibrosis is an issue I will use a larger Tru-Cut because these do not tend to bleed because they’re basically a scar with liver tissue in it. Whereas a hypoechoic liver that could be mast cell I will use a smaller gauge needle or do aspirates first and see how the tissue behaves and then do a Tru-Cut if necessary. I never Tru-Cut passive congestion levers because the liver is not the problem and those cases anyway because all they do is bleed because it’s like doing a Tru-Cut on a full sponge.
In the future we will be doing downloadable power points on many different subjects in internal medicine and will have CE credits attached in quiz format. This is one of the power points I intend on doing.
To help this helps and again welcome to the community
Usually no problems with FNA
Usually no problems with FNA cytology using a 23-25G needle.
Prior to a Tru-Cut will do PT/PTT and pretreat with fresh frozen plasma if prolonged; as well look at platelet counts and will not do if sub-normal.
Usually no problems with FNA
Usually no problems with FNA cytology using a 23-25G needle.
Prior to a Tru-Cut will do PT/PTT and pretreat with fresh frozen plasma if prolonged; as well look at platelet counts and will not do if sub-normal.
Thank you Dr. Lindquist,
Thank you Dr. Lindquist, great ideas to consider. I usually use 25g needles and do not do aspiration (I always start with no aspiration (I usually get nice samples), and if I get nothing then I consider aspiration) is this something everybody else does?
In you experience what do you do if a bleeding occurs after a tru-cut? What are your recommendations for the vets in the clinic once the bleeding is happening? Thanks again. Great website
Thank you Dr. Lindquist,
Thank you Dr. Lindquist, great ideas to consider. I usually use 25g needles and do not do aspiration (I always start with no aspiration (I usually get nice samples), and if I get nothing then I consider aspiration) is this something everybody else does?
In you experience what do you do if a bleeding occurs after a tru-cut? What are your recommendations for the vets in the clinic once the bleeding is happening? Thanks again. Great website
Thank you Dr. Lobetti, good
Thank you Dr. Lobetti, good information! Ill keep it in mind 🙂 Same question for you, what do you do if bleeding occurs once you have taken a tru-cut biopsy? Also I add one more thing, Which are your favorite brands of tru-cut needles (size, brand, models) Thanks again.
Thank you Dr. Lobetti, good
Thank you Dr. Lobetti, good information! Ill keep it in mind 🙂 Same question for you, what do you do if bleeding occurs once you have taken a tru-cut biopsy? Also I add one more thing, Which are your favorite brands of tru-cut needles (size, brand, models) Thanks again.
So far been very lucky as
So far been very lucky as bleeding has only been transient – tend to monitor by repeat scans and plasma transfusion if not done before. Could consider abdominal bandage and if ongoing would have to go in surgically.
I tend to use a 14 G automated biopsy gun made by Ascot Medical.
So far been very lucky as
So far been very lucky as bleeding has only been transient – tend to monitor by repeat scans and plasma transfusion if not done before. Could consider abdominal bandage and if ongoing would have to go in surgically.
I tend to use a 14 G automated biopsy gun made by Ascot Medical.
Dummy me never thought of the
Dummy me never thought of the fresh frozen plasma idea but tough to justify keeping that amongst the cold beer in the cooler on the road being a road warrior and all:) You internists get all the cool stuff! Thx for the post Remo.
Veronica, I usually just have the tech apply direct pressure with a gauze stack for 2x the aptt value just as a point of reference. I think over time you learn what you can stick aggressively and what you should tread lightly on like a bx on a Cushingoid suppurative hepatitis liver (jello pudding factor..has no integrity to the tissue)…it just looks mushy where I will start with 18g and move bigger if need be or a CAH liver where I will do a 14g or other harpoon as its tough to make a scar bleed.
Dummy me never thought of the
Dummy me never thought of the fresh frozen plasma idea but tough to justify keeping that amongst the cold beer in the cooler on the road being a road warrior and all:) You internists get all the cool stuff! Thx for the post Remo.
Veronica, I usually just have the tech apply direct pressure with a gauze stack for 2x the aptt value just as a point of reference. I think over time you learn what you can stick aggressively and what you should tread lightly on like a bx on a Cushingoid suppurative hepatitis liver (jello pudding factor..has no integrity to the tissue)…it just looks mushy where I will start with 18g and move bigger if need be or a CAH liver where I will do a 14g or other harpoon as its tough to make a scar bleed.
veronica go to the pathology
veronica go to the pathology search and type in suppurative hepatitis and there are a ton of various hepatitis hits there
http://www.sonopath.com/case-studies/search
Check out Ozzie (03 00201), the lipidosis diffuse hyperechoic liver. This I would tread lightly on maybe fna first because its a mushy liver.
then go to Violet (03 00908) which is a cah liver notable for the increased portal markings. These I go bigger 16-14g. I think you can see the difference…like a golfer choosing the right club:) what do I know I can barely play mini golf but you get the idea.
BTW you can also just put in the case number ion the pathology search and come up with a specific case:)
veronica go to the pathology
veronica go to the pathology search and type in suppurative hepatitis and there are a ton of various hepatitis hits there
http://www.sonopath.com/case-studies/search
Check out Ozzie (03 00201), the lipidosis diffuse hyperechoic liver. This I would tread lightly on maybe fna first because its a mushy liver.
then go to Violet (03 00908) which is a cah liver notable for the increased portal markings. These I go bigger 16-14g. I think you can see the difference…like a golfer choosing the right club:) what do I know I can barely play mini golf but you get the idea.
BTW you can also just put in the case number ion the pathology search and come up with a specific case:)