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Coagulopathy in Cirrhosis

Garren Montgomery, John Laurenzano

Background

  • The liver is responsible for production of both pro- (factor II, V, VII, IV, X, and XI) and anti-coagulants (protein C, S) in hemostasis. Factor VIII is the only one not made by the liver.
  • Thrombocytopenia is caused by splenic sequestration from portal HTN, failure to produce thrombopoietin (TPO), and bone marrow failure

Evaluation

  • INR/PT, and PTT are poorly reflective of bleeding risk

  • TEG screens and other measures of comprehensive coagulation in cirrhotics

Management

  • Even in bleeding, there is no need to intervene on an INR or platelet value

  • Pre-procedural FFP is not recommended, even in the presence of bleeding, but is frequently requested by different proceduralists

  • Low risk procedures (i.e., paracentesis) do not require pre-procedural blood products

  • In bleeding pts, the following are recommended per AASLD and AGA guidelines

    • IV Vitamin K 10mg x 3 days
    • FFP: Not recommended, unless as part of a balanced transfusion effort to avoid transfusion related coagulopathy, or if a TEG screen suggests potential benefit
    • Cryoprecipitate: if fibrinogen < 120
    • Platelets: No specific targets regardless of bleeding. Pre-procedurally, recommend >50

  • Appropriate DVT ppx should be given with few exceptions (plts <50k, active hemorrhage)

  • For TEG transfusion recommendations are as follows:

    • 10 mg/kg FFP if R-time >10 minutes
    • 1u Plts if maximum amplitude <55 mm
    • 5u cryo if alpha angle <45
Last update: 2022-06-21 11:15:36