Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial.
Bleeding is a feared complication of invasive procedures in patients with cirrhosis and significant coagulopathy (as defined by routine coagulation tests) and is used to justify preprocedure use of fresh frozen plasma (FFP) and/or platelets (PLT). Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet count), and its use may avoid unnecessary blood product transfusion in patients with cirrhosis and significant coagulopathy (defined in this study as INR >1.8 and/or platelet count <50 × 10(9) /L) who will be undergoing an invasive procedure. Sixty patients were randomly allocated to TEG-guided transfusion strategy or standard of care (SOC; 1:1 TEG:SOC). The TEG group would receive FFP if the reaction time (r) was >40 min and/or PLT if maximum amplitude (MA) was <30 mm. All SOC patients received FFP and/or PLT per hospital guidelines. Endpoints were blood product use and bleeding complications. Baseline characteristics of the two groups were similar. Per protocol, all subjects in the SOC group received blood product transfusions versus 5 in the TEG group (100% vs. 16.7%; P < 0.0001). Sixteen SOC (53.3%) received FFP, 10 (33.3%) PLT, and 4 (13.3%) both FFP and PLT. In the TEG group, none received FFP alone (P < 0.0001 vs. SOC), 2 received PLT (6.7%; P = 0.009 vs. SOC), and 3 both FFP and PLT (not significant). Postprocedure bleeding occurred in only 1 patient (SOC group) after large-volume paracentesis.


CONCLUSIONS
In patients with cirrhosis and significant coagulopathy before invasive procedures, TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to SOC (transfusion guided by INR and platelet count), without an increase in bleeding complications. Remarkably, even in patients with significant coagulopathy, postprocedure bleeding was rare, indicating that TEG thresholds should be reevaluated.
Division of Anesthesiology and Intensive Care Unit, Department of Surgery, AOU Policlinico di Modena, Modena, Italy.
Lesley
L
De Pietri
Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy.
Marcello
M
Bianchini
Transplantation Unit, Department of Surgery, Polytechnic University of Marche, Ancona, Italy.
Roberto
R
Montalti
Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy.
Nicola
N
De Maria
Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy.
Tommaso
T
Di Maira
Division of Anesthesiology and Intensive Care Unit, Department of Surgery, AOU Policlinico di Modena, Modena, Italy.
Bruno
B
Begliomini
Department of Surgery, AOU Policlinico di Modena, Modena Italy.
Giorgio Enrico
GE
Gerunda
Transplantation Unit, Department of Surgery, AOU Policlinico di Modena, Modena Italy.
Fabrizio
F
di Benedetto
Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy.|Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, United States.
Guadalupe
G
Garcia-Tsao
Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy.
Erica
E
Villa
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000150:complications*; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D010949:Plasma; D017713:Platelet Transfusion; D011300:Preoperative Care / Q000379:methods*; D012720:Severity of Illness Index; D013916:Thrombelastography; D055815:Young Adult