Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial

Comparison of relaxed verses standard cut-offs of rotational thromboelastometry for guiding blood product use before invasive procedures in advanced cirrhosis: a randomized controlled trial

BACKGROUND

The cut-offs of viscoelastic hemostatic assays used for guiding blood products transfusion in patients with cirrhosis undergoing invasive procedures are arbitrary. The aim of this study was to evaluate the efficacy and safety of two different ROTEM thresholds ["relaxed" ROTEM thresholds vs. "conventional" thresholds used in liver transplantation] for prophylactic blood product transfusion for invasive procedures in advanced cirrhosis patients with impaired traditional coagulation.

MATERIAL AND METHODS

Patients with advanced cirrhosis scheduled to undergo invasive procedures with high inherent procedure bleeding risk or low inherent procedure bleeding risk along with the presence of any adverse patient specific factors, and abnormalities on conventional coagulation tests requiring correction (any of the following: platelet count < 30 × 109/L, INR > 2.0, and plasma fibrinogen < 100 mg/dL), were randomized to receive correction based on standard ROTEM criteria (n = 519, MELD = 26.5 ± 7.4, CTP score = 12.4 ± 2.3, intrinsic low-risk procedure with any high-risk patient factors = 72.2%, intrinsic high-risk procedure with/without high-risk patient factors = 27.8%) or relaxed ROTEM criteria (n = 524, MELD = 25.6 ± 8.0, CTP score = 12.2 ± 2.7, intrinsic low-risk procedure with any high-risk patient factors = 64.1%, intrinsic high-risk procedure with/without high-risk patient factors = 35.9%). Patients in the standard and relaxed criteria groups received blood components using the following triggers, respectively: Fresh frozen plasma (FFP, 10 ml/kg) when EXTEM-CT > 80 or > 90 s; one pooled of single donor platelet unit or 6 pooled units of random donor platelet when EXTEM-MCF/ FIBTEM-MCF < 35/ ≥ 8 mm or < 30/ ≥ 7 mm; and 5 pooled units of cryoprecipitate if EXTEM-MCF/ FIBTEM-MCF < 35 / < 8 mm or < 30/ < 7 mm. The primary outcome measure was the proportion of patients requiring any blood products transfusion (i.e., FFP /platelets /cryoprecipitate).

RESULTS

The proportion of patients transfused any blood product (FFP, platelets or cryoprecipitate) was 287/524 (54.8%) in the relaxed ROTEM group versus 352/519 (67.8%) in the standard ROTEM group (p < 0.001). Procedure-related bleeding and non-bleeding complications and 28-day mortality were similar in both the groups.

CONCLUSIONS

Relaxation of ROTEM cut-offs leads to lower prophylactic blood products transfusions without increased risk of bleeding in patients with advanced cirrhosis undergoing invasive procedures.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

[Diagnostics and management of perioperative bleeding disorders]

Perioperative bleeding is and remains a major complication during and after surgical interventions, resulting in increased morbidity and mortality. The main causes of a non-primary vascular-related bleeding are congenital or multifactorial pre-existing hemostatic disorders that have not yet been diagnosed, the operating procedure itself and acquired hemostatic abnormalities as a secondary phenomenon, e.g., after excessive volume depletion in hypothermia, trauma or extracorporeal circulation, concomitant hypothermia and loss or consumption of coagulation factors and thrombocytes. Beginning with the preoperative preparation, including an extensive medical history, the detection of potential risk factors for increased bleeding including the precise description of current medication is required and prophylactic strategies and procedures should be initiated. In cases of excessive bleeding it is essential to implement adequate diagnostic and therapeutic algorithms, which are suitable for the partly complex and variable alterations of the hemostasis (e.g., in interventions after trauma or with extracorporeal circulation). A multimodal management is necessary to improve the patient's outcome, to limit the administration of blood products to that which is absolutely necessary and to minimize the risks associated with transfusion.

Acute-on-Chronic Liver Failure: Steps Towards Consensus

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Coagulation Abnormalities in Chronic Liver Disease

Chronic liver disease is a frequently encountered disorder and a major concern worldwide with a complex pathophysiology, which often affects the hemostatic system. Such alterations, which affect both primary and secondary hemostasis, are heterogenous, including prohemorrhagic (i.e., decreased coagulation factors, increased fibrinolysis, thrombocytopenia, and platelet dysfunction) and prothrombotic (i.e., decreased natural anticoagulants) changes. As a consequence of this unstable balance, patients with liver cirrhosis may experience both hemorrhagic complications and venous thromboembolic events, which are often unpredictable and whose management is particularly challenging for clinicians. This narrative review will address the most recent advances in the pathophysiology of key derangements of hemostasis in patients with chronic liver disease, focusing on their clinical implications and management.

Prediction and prevention of post-procedural bleedings in patients with cirrhosis

Although post-procedural bleedings are infrequent in patients with cirrhosis, they are associated with significant morbidity and mortality. Therefore, predicting and preventing such bleedings is important. Established predictors of post-procedural bleeding include high-bleeding risk procedure, severe cirrhosis and high body mass index; prognostic value of anemia, acute kidney injury and bacterial infection is more uncertain. While prothrombin time and international normalized ratio do not predict post-procedural bleeding, some evidence suggests that platelet count, whole blood thrombin generation assay and viscoelastic tests may be helpful in this context. Prevention of postprocedural bleeding involves careful management of antithrombotic drugs during the periprocedural period. Patients with cirrhosis present unique challenges due to altered pharmacokinetics and pharmacodynamics of antithrombotic drugs, but there is a lack of dedicated studies specifically focused on this patient population. Guidelines for periprocedural management of antithrombotic drugs developed for patients without liver disease are thus applied to those with cirrhosis. Some technical aspects may decrease the risk of post-procedural bleeding, namely ultrasoundguidance, opting for transjugular route rather than percutaneous route, and the level of expertise of the operator. The effectiveness of platelet transfusions or thrombopoietin-receptor agonists remains uncertain. Transfusion of fresh-frozen plasma, of fibrinogen, and administration of tranexamic acid are not recommended for reducing post-procedural bleeding in patients with cirrhosis. In conclusion, prediction of post-procedural requires a global approach taking into account the patients characteristics, the risk of the procedure, and the platelet count. There is little data to support prophylactic correction of hemostasis, and dedicated studies are needed.

Viscoelastic haemostatic assays to guide therapy in elective surgery: an updated systematic review and meta-analysis

BACKGROUND

Patients undergoing major surgery frequently experience major uncontrolled bleeding. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of using viscoelastic haemostatic assays to manage peri-operative bleeding in elective surgery.

METHODS

We searched PubMed/MEDLINE and Embase databases for randomised controlled trials according to pre-determined criteria. The primary outcomes were blood product requirements; duration of stay in the operating theatre or ICU; and surgical reintervention rate.

RESULTS

We included 20 randomised controlled trials. The overall risk of bias was low to moderate. Twelve studies used thromboelastography-based transfusion algorithms, while eight used thromboelastometry. Viscoelastic haemostatic assay-guided therapy was associated with a statistically significant reduction in transfusion of red blood cells (standardised mean difference (95%CI) 0.16 (-0.29 to 0.02)), platelets (standardised mean difference (95%CI) -0.33 (-0.56 to -0.10)) and fresh frozen plasma (standardised mean difference (95%CI) -0.64 (-1.01 to -0.28)). There was no evidence of an effect of viscoelastic haemostatic assay-guided therapy on surgical reintervention (relative risk (95%CI) 1.09 (0.70-1.69)). Viscoelastic haemostatic assay-guided therapy was associated with lower blood loss and shorter ICU duration of stay. There was no evidence of any effect on total duration of stay and all-cause mortality.

CONCLUSIONS

Viscoelastic haemostatic assay-guided therapy may reduce peri-operative blood product transfusion requirements and blood loss during major elective surgery, with no discernible effect on patient-centred outcomes. The overall quality of evidence was modest.

Rotational Thromboelastometry Reduces the Need for Preemptive Transfusion in Cirrhosis: A Randomized Controlled Trial (NCT:05698134)

Backgrounds and aim

Viscoelastic tests (VET) like rotational thromboelastometry (ROTEM) assess global hemostasis in cirrhosis. We aimed to assess whether ROTEM-guided blood product transfusion results in lower blood product requirements in patients with cirrhosis undergoing elective invasive procedures as compared to standard of care (SOC) based on conventional coagulation test (CCT).

Methods

In this open label randomized controlled trial, patients with cirrhosis and abnormal CCT who were undergoing an invasive procedure were randomized to receive blood products either by ROTEM-guidance or SOC. The primary outcome was the difference in blood products (fresh frozen plasma (FFP) or platelets) transfused between the groups. The secondary outcome was procedure-related bleeding or complications within 7 days of the procedure. The trial protocol is registered at clinicaltrails.gov; NCT05698134.

Results

From August 2021 to January 2023, a total of 40 patients were recruited (ROTEM (n = 20) and SOC (n = 20)). The trial was terminated earlier during interim analyses due to compelling benefit in the ROTEM group after a scheduled interim analysis. The ROTEM group required substantially less blood transfusion than the SOC group (40% [8/20] vs 100% [20/20], P < 0.001). The benefit was consistent across all types of blood product, including fresh frozen plasma (<0.001) and pooled platelets (P = 0.046). No patients experienced clinically significant bleeding events. Transfusion-associated adverse events occurred in one patient (5%) in the SOC group (allergic reaction) and none in the ROTEM group (P = NS). The mortality in both groups at 30 and 90 days was similar.

Conclusions

Viscoelastic tests like ROTEM provide global assessment of hemostasis in patients with cirrhosis. Institution of ROTEM based transfusion strategy significantly reduces the need for blood product transfusion in patients with cirrhosis undergoing elective procedure without any increased risk of bleeding events.

Clinical trial number

NCT05698134.

Thromboelastography or rotational thromboelastometry guided algorithms in bleeding patients: An updated systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Bleeding patients face significant morbidity and mortality due to impaired haemostasis. Haemostatic resuscitation has evolved, yet the optimal approach remains unclear. The primary objective was to assess the benefits and risks of transfusion guided by TEG/ROTEM versus standard of care in bleeding patients in an updated review.

METHODS

This systematic review of randomised controlled trials with meta-analyses and trial sequential analysis was conducted according to Cochrane Collaboration methodology, PRISMA and GRADE guidelines. A literature search was conducted in five major databases. Both paediatric and adult patients were included. The primary outcome was mortality, and secondary outcomes were the administration of blood products, blood loss, surgical reintervention, and dialysis-dependent renal injury.

RESULTS

This systematic review included 31 randomised trials (n = 2756), with most patients undergoing elective cardiac surgery. TEG-/ROTEM-guided algorithms reduced the amount of transfused fresh frozen plasma (RR 0.5, 95% CI 0.32-0.72, I2: 94%), platelets (RR 0.7, 95% CI 0.55-0.91, I2: 57%), the risk for surgical reintervention (RR 0.65, 95% CI 0.47-0.94, I2: 0%), and bleeding with a standard mean difference of -0.31 (95% CI -0.55 to -0.08, I2: 75%). No statistically significant difference was demonstrated for mortality (RR 0.76, 95% CI 0.57-1.00, I2: 5%). According to GRADE methodology, the certainty of the evidence was very low for all outcomes. Trial sequential analysis of mortality analysis indicated that 54% of the optimal information size was reached with an alpha-boundary RR of 0.81 (95% CI 0.63-1.03).

CONCLUSIONS

TEG-/ROTEM-guided transfusion algorithms may reduce the risk of mortality, bleeding volume, and the need for fresh frozen plasma and platelets, but the evidence is very uncertain. Further, the results were primarily based on the adult population undergoing elective cardiac surgery.

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

EASL Clinical Practice Guidelines on liver transplantation

Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.

Unravelling the coagulation paradox in liver cirrhosis: challenges and insights

Patients with liver disease experience complex haemostatic changes leading to a state of 'rebalanced haemostasis' that may shift towards bleeding or thrombosis due to complications like kidney dysfunction, bacterial infection, or acute-on-chronic liver failure. Traditional coagulation tests inadequately capture haemostasis in cirrhosis, whereas advanced assays like thrombin generation assay and viscoelastic testing offer better insights but remain limited in clinical outcome prediction or guiding pre-procedural prophylaxis.Contrary to the traditional view of cirrhosis as a bleeding disorder, recent evidence highlights a paradox of higher venous thromboembolism incidence in hospitalised cirrhotic patients. Misconceptions about 'auto-anticoagulation' and concerns about anticoagulation safety hinder consistent thromboprophylaxis. Emerging data suggest that low molecular weight heparin is safe and effective in cirrhotic patients, supporting more evidence-based thromboprophylaxis. For thrombotic events or conditions like atrial fibrillation, therapeutic anticoagulation is recommended, and may offer additional benefits, such as attenuating liver fibrosis and portal hypertension. However, anticoagulation is not established as a core therapy in cirrhosis, given safety concerns in advanced disease.Bleeding remains a significant challenge in cirrhosis, with management focusing on specific aetiologies, including portal hypertension or procedural injuries. In pre-procedural planning, there is a trend of unnecessary blood product use, often based on an assumed bleeding risk. Rational pre-procedural planning should minimize unnecessary transfusions, optimise modifiable risks, and include a plan for managing potential bleeding.This review aims to clarify the 'coagulation paradox' in cirrhosis, promoting a nuanced, individualized approach to managing bleeding and thrombosis in chronic liver disease.

Cirrhosis Progression Is Not Associated with Clinically Significant Alterations in Global Hemostasis Assessed by Thromboelastography

(1) Background: Cirrhosis is associated with frequent alterations in standard coagulation tests that do not adequately reflect hemostasis. Thromboelastography provides a global assessment of coagulation and evaluates the functional status of clotting factors, fibrinogen, platelets, and fibrinolysis. The study aimed to assess whether liver disease severity leads to progressive alterations in the thromboelastography-based assessment of coagulation. (2) Methods: Consecutive patients with cirrhosis and abnormal standard coagulation tests (at least one of International Normalized Ratio > 2, platelet count < 50 × 103/µL, fibrinogen < 200 mg/dL) were analyzed using native thromboelastography. (3) Results: A total of 106 patients were included, of whom 69 (65.1%) had a normal thromboelastography. While the standard coagulation tests were significantly worse in patients in the Child C group (n = 62, 58.5%) than in patients staged in Child A and B, no significant differences existed between any of the thromboelastography variables. Of the 50 patients (47.1%) with an International Normalized Ratio > 2, only two patients (4%) had features of hypocoagulation, while 26% had features of hypercoagulability on thromboelastography. Patients with a platelet count < 50 × 103/µL had significantly lower platelet function as assessed by thromboelastography, yet only eight patients (20%) met the criteria for platelet transfusion. A thromboelastography-based transfusion protocol might lead to a 94.6% reduction in blood product transfusion indications in a simulation where the included patients would require interventional procedures. (4) Conclusion: Standard coagulation tests showed a poor correlation with thromboelastography. Based on thromboelastography, patients with severe, decompensated liver disease have a preserved hemostasis balance despite abnormal standard coagulation tests. Therefore, standard coagulation tests should not be used to guide the administration of blood products in patients with cirrhosis.

Should viscoelastic testing be a standard point-of-care test on all intensive care units?

Viscoelastic tests (VETs) have transformed assessment of haemostasis and transfusion practices in trauma, cardiac and liver transplantation centres. Impaired haemostasis is a common problem on the general intensive care unit (ICU), but routine use of VETs is rare. We have accordingly reviewed the evidence to determine whether there is evidence to support the use of VETs as a standard point of care test on all ICUs in assessing and managing patients. The benefits of using VETs in the management of major haemorrhage, namely faster identification of a coagulopathy, in particular early detection of fibrinolysis, and reduced transfusion requirements for blood products have been seen in the general ICU. Validation of treatments algorithms is now required to standardise practice. There is also emerging evidence to support the use of VETs to guide urgent treatment decisions in patients with a coagulopathy or in patients taking anti-coagulants or anti-platelet therapies. We recommend that departments independently review the feasibility of setting up a viscoelastic point of care service which considers the applicability to their patient cohort, the financial cost and the personnel required.

Managing Multiorgan Failure in Acute on Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is defined as a clinical syndrome that develops in patients with chronic liver disease characterized by the presence of organ failure and high short-term mortality, although there is still no worldwide consensus on diagnostic criteria. Management of ACLF is mainly based on treatment of "precipitating factors" (the most common are infections, alcohol-associated hepatitis, hepatitis B flare, and bleeding) and support of organ failure, which often requires admission to the intensive care unit. Liver transplantation should be considered in patients with ACLF grades 2 to 3 as a potentially life-saving treatment. When a transplant is not indicated, palliative care should be considered after 3 to 7 days of full organ support in patients with at least four organ failures or a CLIF-C ACLF score of >70. This review summarizes the current knowledge on the management of organ failure in patients with ACLF, focusing on recent advances.

Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN)

Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients.

Thromboelastography-Guided versus Standard-of-Care or On-Demand Platelet Transfusion in Patients with Cirrhosis and Thrombocytopenia Undergoing Procedures: A Randomized Controlled Trial

PURPOSE

To determine the rate of platelet transfusion in patients with cirrhosis and severe thrombocytopenia (platelet counts <50 × 109/L) undergoing high-risk invasive procedures when prescribed by thromboelastography (TEG) compared with empirical and on-demand transfusion strategies.

MATERIALS AND METHODS

This was a single-center, single-blinded, randomized controlled trial. Patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures were randomized into 3 groups: TEG group, transfusions based on TEG parameters; standard of care (SOC) group, 3 units of random donor platelets before procedure; and on-demand group, transfusions based on procedural adverse events/clinician's discretion. The primary outcome was periprocedural platelet transfusion in each arm.

RESULTS

Eighty-seven patients were randomized (29 in each group) with no significant differences in demographics/coagulation profile/procedures. The median platelet count was 33 × 109/L (interquartile range, 26-43 × 109/L). Percutaneous liver biopsy was the most common procedure (46, 52.9%). Significantly lower number of patients in the TEG group received platelets (4 cases, 13.8%; 95% CI, 3.9-31.7) compared with SOC group (100%; 95% CI, 88.1-100; P < .001). Four patients in the on-demand group received platelets (13.8%; 95% CI, 3.9-31.7). Minor (World Health Organization [WHO] Grade 2) procedure-related bleeding occurred in 3 (10%; 95% CI, 2.2-27.4) patients in the TEG-guided transfusion group compared with 1 (3.4%; 95% CI, 0.1-17.8) patient each in the SOC and on-demand groups (P = .43), although the study was not powered for comparison of bleeding rates. No bleeding-related mortality was observed in any of the 3 groups.

CONCLUSIONS

TEG-prescribed transfusion reduced prophylactic transfusions in patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures. The study was not powered for comparison of bleeding rates.

Risk of bleeding after abdominal paracentesis in patients with chronic liver disease and coagulopathy: A systematic review and meta-analysis

Abdominal paracentesis is a common procedure performed for both diagnostic and therapeutic purposes in patients with chronic liver disease and ascites. This review aims to provide an overview of the current evidence on the risk of bleeding associated with abdominal paracentesis. Electronic search was performed using PubMed, MEDLINE, and Ovid EMBASE from inception to 29 October 2023. Studies were included if they examined the risk of bleeding post-abdominal paracentesis or the efficacy of interventions to reduce bleeding in patients with chronic liver disease. Random-effects model was used to calculate the pooled proportions of bleeding events following abdominal paracentesis. Heterogeneity was determined by I 2, τ2 statistics, and P-value. Eight studies were included for review. Six studies reported incident events of post-abdominal paracentesis bleeding. Pooled proportion of bleeding events following abdominal paracentesis was 0.32% (95% CI: 0.15-0.69%). The mean values for pre-procedural INR and platelet count of patients in these studies ranged between 1.4 and 2.0, and 50 and 153 × 109/L, respectively. The highest recorded INR was 8.7, and the lowest platelet count was 19 × 109/L. Major bleeding after abdominal paracentesis occurred in 0-0.97% of the study cohorts. Two studies demonstrated that the use of thromboelastography (TEG) before paracentesis in patients with chronic liver disease identified those at risk of procedure-related bleeding and reduced transfusion requirements. The overall risk of major bleeding after abdominal paracentesis is low in patients with chronic liver disease and coagulopathy. TEG may be used to predict bleeding risk and guide transfusion requirements.

Thromboelastography parameters in chronic viral liver disease and liver resection: a retrospective study

INTRODUCTION

Thromboelastography (TEG) provides a global assessment of haemostasis and is potentially applicable to liver disease. The present study aimed to explore the utility of TEG for the evaluation of patients with chronic viral liver disease, which has previously not been investigated.

METHODS

Demographic characteristics and TEG parameters were collected before surgery. Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were used to categorise stages of liver cirrhosis. Liver resections were classified as low, medium and high complexity.

RESULTS

A total of 344 patients were included. Results showed significantly longer K-time, smaller α-angle and lower maximum amplitude (MA) with increasing liver disease severity as measured by the CTP and MELD scores ( P < 0.05 for all). After multivariable adjustment (including age, sex, liver disease aetiology, alanine aminotransferase [ALT], aspartate aminotransferase [AST], albumin, total bilirubin, haemoglobin and platelet count), TEG parameters (except R-times) were either weakly or inversely related to the severity of liver disease as defined by the MELD score (absolute r < 0.2 and P < 0.05 for all except R-times). R-times obtained before surgery were weakly correlated with perioperative blood loss ( r < 0.2 and P < 0.05 for all).

CONCLUSIONS

The correlation between TEG parameters and severity of liver disease was weak. In addition, R-times obtained before liver resection were weakly associated with perioperative blood loss after multivariable adjustments. TEG utility for haemostasis assessment and prediction of blood loss during liver resection should be further explored in high-quality studies.

Preoperative risk evaluation and optimization for patients with liver disease

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

Does the Use of Viscoelastic Hemostatic Assays for Periprocedural Hemostasis Management in Liver Disease Improve Clinical Outcomes?

Routine hemostasis parameters such as prothrombin time and fibrinogen are frequently abnormal in patients with chronic liver disease and have been demonstrated to be poor predictors for periprocedural bleeding. Alterations in procoagulant and anticoagulant factors in this population result in a state of rebalanced hemostasis, which is not reflected by routine hemostatic measures. Viscoelastic hemostatic assays (VHA) present a point of care measure of global hemostasis with an emerging role in guiding transfusion in the liver transplant setting. The potential role for VHA in guiding periprocedural transfusion is unknown. Here we critically appraise the available limited evidence on the use of VHA to guide prophylactic treatment in patients with cirrhosis undergoing procedures. We assess whether the impact of a VHA-guided approach improves clinical outcomes. Suggested areas for future research with a focus on clinically relevant outcomes, particularly periprocedural bleeding, are highlighted.

The Role of Viscoelastic Testing in Assessing Hemostasis: A Challenge to Standard Laboratory Assays?

Viscoelastic testing is increasingly being used in clinical and research settings to assess hemostasis. Indeed, there are potential situations in which viscoelastic testing is reportedly superior to standard routine laboratory testing for hemostasis. We report the current testing platforms and terminology, as well as providing a concise narrative review of the published evidence to guide its use in various clinical settings. Notably, there is increasing evidence of the potential utility of viscoelastic testing for assessment of direct oral anticoagulants, and bleeding associated with chronic liver disease, orthotopic liver transplantation, cardiac surgery, trauma, obstetrics and pediatrics.

Surgical risk stratification in patients with cirrhosis

Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.

Review article: Evaluation and care of the critically ill patient with cirrhosis

BACKGROUND

The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients.

AIM

Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care.

METHODS

We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care.

RESULTS

Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource.

CONCLUSIONS

Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.

Impact of coagulopathy assessment with thromboelastography and thromboelastometry on transfusion requirements in critically ill cirrhosis with nonvariceal bleeding: A prospective observational study

Background

Viscoelastic tests are now routinely used for coagulopathy correction in patients with cirrhosis. Thromboelastography (TEG®) and rotational thromboelastometry (RoTEM®) are the most widely studied tests in this population. However, they have not been compared with each other in critically ill patients with liver disease presenting with nonvariceal bleed. Hence, we aimed to compare these tests for coagulopathy correction in patients with liver disease presenting with nonvariceal bleeding.

Methods

Sixty adult patients with liver cirrhosis presented to the liver intensive care unit, presenting with a nonvariceal upper gastrointestinal (GI) bleed (diagnosed by doing upper GI endoscopy which revealed bleeding from a nonvariceal source) oral or nasal bleed were enrolled. The patients were allocated to the TEG® group (Group T) or RoTEM® group (Group R) depending on the immediate availability of the viscoelastic test. Coagulopathy correction was done in each group as per established protocols and the results were compared.

Results

There was a significant difference in the fresh frozen plasma (FFP) transfusion between the groups. The TEG® group received more FFP when compared to the RoTEM® group (P = 0.001).

Conclusion

RoTEM®-based coagulopathy correction leads to lesser use of blood products with similar control of bleeding when compared to TEG, in critically ill patients with cirrhosis.

Acquired bleeding disorders

Acquired bleeding disorders can develop in previously healthy people irrespective of age or gender but are particularly common in patients with certain underlying conditions. Here, we review recent advances in the management of acquired haemophilia A (AHA), acquired von Willebrand syndrome (AVWS), and patients with hemostatic abnormalities due to chronic liver disease (CLD). Patients with AHA can now benefit from prophylaxis with emicizumab, a therapeutic antibody that mimics the function of activated coagulation factor VIII. The treatment of AVWS remains challenging in many situations and requires careful consideration of the underlying condition. Haemostatic abnormalities in CLD are often compensated by proportional reduction in pro and anti-haemostatic factors resulting in sustained or even increased thrombin generation. Consequently, bleeding in CLD is rarely caused by haemostatic failure and infusion of plasma or coagulation factor concentrates may not be effective.

Expert opinion on bleeding risk from invasive procedures in cirrhosis

Background & Aims

Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines.

Methods

All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as "high risk" or "low risk" with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as "consensus" was ≥75% agreement.

Results

Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as "high risk", primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as "low risk", primarily "diagnostic" procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures.

Conclusions

This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis.

Impact and implications

Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis.

Plasma: indications, controversies, and opportunities

Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.

Treating periprocedural bleeding in patients with cirrhosis

Patients with cirrhosis are known to have an abnormal coagulation status, which is a particular concern when planning invasive procedures in which blood loss is possible or predictable. Careful consideration must be given to the bleeding risk for each individual patient and coagulation management strategies should be established in advance of procedural interventions, where possible. Perioperative clinical decision-making should utilize viscoelastic testing in addition to usual assessments, where possible, and focus on the well-established three pillars of patient blood management: optimization of erythropoiesis, minimization of bleeding and blood loss, and management of anemia. Restrictive transfusion policies, careful hemostatic monitoring, and a proactive approach to predicting and preventing bleeding on an individual patient basis should be central to managing perioperative bleeding in the fragile patient population with cirrhosis. This review discusses coagulation assessments and bleeding management techniques necessary before, during, and after surgical interventions in patients with cirrhosis, and provides expert clinical opinion and physician experience on the perioperative management of these patients.

Efficacy of fresh frozen plasma transfusion in decompensated cirrhosis patients with coagulopathy admitted to ICU: a retrospective cohort study from MIMIC-IV database

We aimed to explore the association between FFP transfusion and outcomes of DC patients with significant coagulopathy. A total of 693 DC patients with significant coagulopathy were analyzed with 233 patients per group after propensity score matching (PSM). Patients who received FFP transfusion were matched with those receiving conventional therapy via PSM. Regression analysis showed FFP transfusion had no benefit in 30-day (HR: 1.08, 95% CI 0.83-1.4), 90-day (HR: 1.03, 95% CI 0.80-1.31) and in-hospital(HR: 1.30, 95% CI 0.90-1.89) mortality, associated with increased risk of liver failure (OR: 3.00, 95% CI 1.78-5.07), kidney failure (OR: 1.90, 95% CI 1.13-3.18), coagulation failure (OR: 2.55, 95% CI 1.52-4.27), respiratory failure (OR: 1.76, 95% CI 1.15-2.69), and circulatory failure (OR: 2.15, 95% CI 1.27-3.64), and even associated with prolonged the LOS ICU (β: 2.61, 95% CI 1.59-3.62) and LOS hospital (β: 6.59, 95% CI 2.62-10.57). In sensitivity analysis, multivariate analysis (HR: 1.09, 95%CI 0.86, 1.38), IPTW (HR: 1.11, 95%CI 0.95-1.29) and CAPS (HR: 1.09, 95% CI 0.86-1.38) showed FFP transfusion had no beneficial effect on the 30-day mortality. Smooth curve fitting demonstrated the risk of liver failure, kidney failure and circulatory failure increased by 3%, 2% and 2% respectively, for each 1 ml/kg increase in FFP transfusion. We found there was no significant difference of CLIF-SOFA and MELD score between the two group on day 0, 3, 7, 14. Compared with the conventional group, INR, APTT, and TBIL in the FFP transfusion group significantly increased, while PaO2/FiO2 significantly decreased within 14 days. In conclusion, FFP transfusion had no beneficial effect on the 30-day, 90-day, in-hospital mortality, was associated with prolonged the LOS ICU and LOS hospital, and the increased risk of liver failure, kidney failure, coagulation failure, respiratory failure and circulatory failure events. However, large, multi-center, randomized controlled trials, prospective cohort studies and external validation are still needed to verify the efficacy of FFP transfusion in the future.

Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.

Reappraisal of the conventional hemostasis tests as predictors of perioperative bleeding in the era of rebalanced hemostasis in cirrhosis

New global laboratory procedures mimicking the in vivo hemostasis process led to the changing paradigm of cirrhosis from the prototype of hemorrhagic diseases to a condition in which hemostasis is normal but fragile, thus justifying the hemorrhagic/thrombotic tendencies that affect these patients. The new paradigm was instrumental to change the management of cirrhosis. For example, international guidelines warn against the entrenched practice of testing patients with conventional hemostasis tests and infusing those with abnormalities with fresh-frozen plasma, coagulation factor concentrates, or platelets, prior to surgery/invasive procedures. These recommendations are, however, largely disattended. The practice of testing patients with the prothrombin time or viscoelastometry and using arbitrary cutoffs to make decisions on perioperative prophylaxis is still common and probably driven by medicolegal issues. There is no doubt that prothrombin time and congeners tests are unable to predict bleeding in cirrhosis. However, it cannot be excluded that some tests may be useful in patients who are severely decompensated. Large prospective collaborative studies are warranted. Enrolled patients should be randomized to receive perioperative prophylaxis based on laboratory testing (eg, viscoelastometry, thrombomodulin-modified thrombin generation) or to usual care. However, for these trials to be useful, a third group of patients who do not receive prophylaxis should be included. In conclusion, until results from these studies are available, physicians attending cirrhosis should refrain from using laboratory tests with arbitrary cutoffs to make decision on perioperative prophylaxis. Decision should be made by considering the clinical history of individual patients and the risk of hemorrhage of specific procedures.

Evaluation of coagulopathy in cirrhotic patients: A scoping review of the utility of viscoelastic testing

BACKGROUND

Cirrhosis causes significant coagulopathy. Traditional coagulation tests may not accurately measure coagulopathy in well-compensated patients with cirrhosis. Viscoelastic tests are functional tests that may better assess coagulopathy in cirrhotic patients.

METHODS

We searched PubMed, ScienceDirect, Google Scholar, and grey literature using terms meaning viscoelastic testing and cirrhosis. After reviewing over 500 titles and abstracts, 40 full-text papers met inclusion criteria.

RESULTS

Twenty-two papers found viscoelastic testing was a better indicator of baseline coagulation than traditional testing in cirrhosis. Nineteen additional papers evaluated the utility of peri-procedural viscoelastic testing and found they led to a reduction in blood product administration without increasing risk of hemorrhage, thrombotic events, or other complications.

CONCLUSIONS

The usage of viscoelastic testing in patients with cirrhosis allows for better assessment of coagulopathy, resulting in improved outcomes. Educating physicians to optimize care of this high-risk group is necessary to further improve their treatment.

Guidelines for the management of coagulation disorders in patients with cirrhosis

Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.

Paying attention to the value of thrombelastography and the impact of postreperfusion syndrome on outcomes of liver transplantation

Only limited information is available about the connection between massive blood transfusion and postoperative survival rates in pediatric liver transplantation. The aim of Gordon's study was to examine the potential impact of perioperative transfusion on postoperative complications and death in young children receiving pediatric living-donor liver transplantation (PLDLT). The authors concluded that transfusion of a red blood cell volume higher than 27.5 mL/kg during the perioperative period is associated with a significant increase in short- and long-term postoperative morbidity and mortality after PLDLT. However, viscoelastic coagulation monitoring was not utilized in the study; instead, only conventional coagulation monitoring was conducted. Overall, the choice of blood coagulation monitoring method during blood transfusion can have a significant impact on patient prognosis. Several studies have shown that the viscoelastic coagulation testing such as thrombelastography (TEG) is highly sensitive and accurate for diagnosing coagulation dysfunction. Indeed, a TEG-guided blood transfusion strategy can improve prognosis. Moreover, postreperfusion syndrome is one of the most common complications of liver transplantation and an important factor affecting the prognosis of patients and should also be included in regression analysis.

How to assess hemostasis in patients with severe liver disease

Patients with advanced liver diseases frequently acquire profound alterations in their hemostatic system. Simultaneous changes in procoagulant and anticoagulant systems result in a reset in the hemostatic balance with a relatively neutral net effect, although there are notable hypocoagulable and hypercoagulable features in the hemostatic system in patients with liver disease. Laboratory and clinical studies have demonstrated that patients have a relatively well-preserved hemostatic system even though routine diagnostic tests of hemostasis (prothrombin time, platelet count) suggest a bleeding tendency. Routine diagnostic tests of hemostasis are unsuitable to assess the hemostatic status of patients with liver disease, as these tests are insensitive for the concurrent prohemostatic and antihemostatic changes in these patients. These tests are, however, frequently requested in patients with liver disease, as they are well established indicators of severity of liver disease. This paper will discuss commonly used diagnostic and research-type hemostatic tests and will outline how test results should be interpreted in patients with liver disease.

Thromboelastography-Guided Correction of Coagulopathy Before Tunneled Central Venous Access in Critically Ill Patients With Liver Disease: A Propensity Score-Matched Study

Importance

Optimal blood product transfusion strategies before tunneled central venous catheter (CVC) placement are required in critically ill coagulopathic patients with liver disease to reduce exposure to allogeneic blood products and mitigate bleeding and thrombotic complications.

Objectives

This study evaluated the safety and efficacy of a thromboelastography-guided transfusion strategy for the correction of coagulopathy in patients with liver disease compared with a conventional transfusion strategy (using international normalized ratio, platelet count, and fibrinogen) before tunneled CVC insertion.

Design Setting and Participants

A retrospective propensity score-matched single-center cohort study was conducted at a quaternary care academic medical center involving 364 patients with liver disease (cirrhosis and acute liver failure) who underwent tunneled CVC insertion in the ICU. Patients were stratified into two groups based on whether they received blood product transfusions based on a thromboelastography-guided or conventional transfusion strategy.

Main Outcomes and Measures

Primary outcomes that were evaluated included the volume, units and cost of blood products (fresh frozen plasma, cryoprecipitate, and platelets) when using a thromboelastography-guided or conventional approach to blood transfusions. Secondary outcomes included the frequency of procedure-related bleeding and thrombotic complications.

Results

The total number of units/volume/cost of fresh frozen plasma (12 U/3,000 mL/$684 vs. 32 U/7,500 mL/$1,824 [p = 0.019]), cryoprecipitate (60 U/1,500 mL/$3,240 vs. 250 U/6,250 mL/$13,500 [p < 0.001]), and platelets (5 U/1,500 mL/$2,610 vs. 13 units/3,900 mL/$6,786 [p = 0.046]) transfused were significantly lower in the thromboelastography-guided transfusion group than in the conventional transfusion group. No differences in the frequency of bleeding/thrombotic events were observed between the two groups.

Conclusions and Relevance

A thromboelastography-guided transfusion strategy for correction of coagulopathy in critically ill patients with liver disease before tunneled CVC insertion, compared with a conventional transfusion strategy, reduces unnecessary exposure to allogeneic blood products and associated costs without increasing the risk for peri-procedural bleeding and thrombotic complications.

Resuscitation and Preparation of the Emergency General Surgery Patient

Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.

Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology

Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.

TEG-based transfusion protocol is associated with decreased blood product use without increased risk of hemoperitoneum

BACKGROUND

Thromboelastography (TEG) informs the need for blood product transfusions to prevent procedural bleeding complications in patients with cirrhosis. We aimed to evaluate the impact of using a TEG-based transfusion protocol on blood product utilization before paracentesis and the post-paracentesis hemoperitoneum (PPH) incidence.

METHODS

We conducted an ambispective analysis of patients with cirrhosis who underwent paracentesis from 2017 to 2021. In May 2019, we enacted a TEG-based transfusion protocol to guide pre-paracentesis blood product use. Patients with platelets < 20,000 or international normalized ratio ≥ 4 underwent TEG and received blood products if r value > 10 min or MA <30 mm. Patients were divided into pre-TEG and post-TEG protocol cohorts based on the date of paracentesis. Pre-paracentesis blood product transfusions in the form of platelets, fresh frozen plasma, and cryoprecipitates were recorded. PPH was defined as a decrease in hemoglobin of ≥1 g and the presence of blood on diagnostic imaging and/or the need for therapeutic intervention.

RESULTS

A total of 483 patients underwent 1281 paracenteses. The main etiologies of cirrhosis were alcohol (43%) and NASH (25%), and the mean MELD-sodium was 22±6. Pre-TEG and post-TEG protocol cohort sizes were similar: 253 patients and 607 paracenteses versus 230 patients and 674 paracenteses. After TEG-protocol implementation, blood product transfusions decreased significantly (228 vs. 49 products, p<0.001) with associated cost savings. One patient in each cohort developed PPH.

CONCLUSION

Implementation of a pre-paracentesis TEG-based transfusion protocol for patients with cirrhosis successfully resulted in decreased blood product use with no associated increase in incidence of PPH.

The Yin and the Yang of Hemostasis in End-Stage Liver Disease

Patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) are prone to thromboses both while on the waiting list and in the perioperative period. This hypercoagulability is associated with significant endothelial dysfunction (ED) due to nitric oxide dysregulation. ED and increased thrombin generation are the main factors responsible for this hypercoagulability. Sepsis alone can significantly alter a patient's coagulation profile. In combination with ESLD, however, sepsis or septic shock are responsible for very complex changes. This makes both the assessment and management of coagulation in septic patients with ESLD very challenging. Viscoelastic testing (VET) is the preferred method of coagulation management in patients with cirrhosis because, as with standard laboratory testing, VET can assess the entire coagulation system including the interaction between both pro- and anticoagulants and platelets.

Procedural-Related Bleeding in Hospitalized Patients With Liver Disease (PROC-BLeeD): An International, Prospective, Multicenter Observational Study

BACKGROUND & AIMS

Hospitalized patients with cirrhosis frequently undergo multiple procedures. The risk of procedural-related bleeding remains unclear, and management is not standardized. We conducted an international, prospective, multicenter study of hospitalized patients with cirrhosis undergoing nonsurgical procedures to establish the incidence of procedural-related bleeding and to identify bleeding risk factors.

METHODS

Hospitalized patients were prospectively enrolled and monitored until surgery, transplantation, death, or 28 days from admission. The study enrolled 1187 patients undergoing 3006 nonsurgical procedures from 20 centers.

RESULTS

A total of 93 procedural-related bleeding events were identified. Bleeding was reported in 6.9% of patient admissions and in 3.0% of the procedures. Major bleeding was reported in 2.3% of patient admissions and in 0.9% of the procedures. Patients with bleeding were more likely to have nonalcoholic steatohepatitis (43.9% vs 30%) and higher body mass index (BMI; 31.2 vs 29.5). Patients with bleeding had a higher Model for End-Stage Liver Disease score at admission (24.5 vs 18.5). A multivariable analysis controlling for center variation found that high-risk procedures (odds ratio [OR], 4.64; 95% confidence interval [CI], 2.44-8.84), Model for End-Stage Liver Disease score (OR, 2.37; 95% CI, 1.46-3.86), and higher BMI (OR, 1.40; 95% CI, 1.10-1.80) independently predicted bleeding. Preprocedure international normalized ratio, platelet level, and antithrombotic use were not predictive of bleeding. Bleeding prophylaxis was used more routinely in patients with bleeding (19.4% vs 7.4%). Patients with bleeding had a significantly higher 28-day risk of death (hazard ratio, 6.91; 95% CI, 4.22-11.31).

CONCLUSIONS

Procedural-related bleeding occurs rarely in hospitalized patients with cirrhosis. Patients with elevated BMI and decompensated liver disease who undergo high-risk procedures may be at risk to bleed. Bleeding is not associated with conventional hemostasis tests, preprocedure prophylaxis, or recent antithrombotic therapy.