Thromboelastographic Guide for Blood Products in Cirrhotics

USE OF THROMBOELASTOGRAPHY TO GUIDE BLOOD PRODUCTS REPLACEMENT IN DECOMPENSATED CIRRHOTIC PATIENTS UNDERGOING INVASIVE PROCEDURES

Blood products are commonly used before invasive procedures in patients with end-stage liver diseases despite cirrhosis being a thrombophylic state. Traditional coagulation tests (namely INR and PLTs count) are known to be unreliable in predicting bleeding risk before invasive procedures and in representing the real coagulation status of cirrhotic patients. Notwithstanding they are still used to guide blood products administration before invasive procedures. Thromboelastography (TEG) has been shown to be effective in detecting signs of hypo-hypercoagulability possibly being an alternative method to guide blood products transfusion. The aim of this randomized controlled study was to evaluate the efficacy of TEG as a guide for blood products transfusion in cirrhotic patients undergoing invasive procedures.

Patients in the TEG group received fresh frozen plasma at the dose of 10 ml/kg of ideal body weight, only if INR was higher than 1.8 and r time longer than 40 minutes. They received platelets at the amount of 1 apheresis Unit, only if platelets count was lower than 50000/μl and MA was shorter than 30 millimeter.

In the SOC group patients received fresh frozen plasma at the dose of 10 ml/kg of ideal body weight, when INR was higher than 1.8. They received platelets at the amount of 1 apheresis Unit, when platelets count was lower than 50000/μl.

A TEG has been performed before invasive procedure and blood products infusion has been decided according to TEG parameters as follow: fresh frozen plasma (FFP 10 ml/kg) in case of r time>40 mm and/or platelets (PLTs 10 units/Kg) for MA<30 mm

Comparison of the number of patients receiving blood products (FFPor PLTs or both), and the amount of blood products between the study groups

Comparison of the number of patients having bleeding episodes after procedure between the study groups

Comparison of the number of patients presenting post-procedures complication other than bleeding between the study groups

Inclusion Criteria: Histologic or imaging-proven liver cirrhosis of any etiology INR>1.8 and/or PLTs count <50x103/μl Exclusion Criteria: Ongoing bleeding Previous or current thrombotic events defined as any documented blood clot in a venous or arterial vessel Ongoing antiplatelet or anticoagulant therapy or stopped less than 7 days before evaluation for the study Presence of sepsis according to ACP-SCCP criteria Hemodialysis performed within 7 days

Azienda Ospedaliero-Universitaria di Modena-Policlinico, Division of Anaesthesiology and Intensive Care Unit