Coagulopathy

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
• Thrombocytopenia is caused by splenic sequestration 2/2 portal HTN, failure to produce thrombopoietin, and bone marrow failure

Evaluation

• INR, PT, and PTT are poorly reflective of bleeding risk
• TEG screens and other measures of comprehensive coagulation are more representative and are available, but are not universally used at VUMC

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
• There is no evidence of benefit, though there is significant risk.
• 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
  • Vitamin K 10mg x 3 days for those who are cholestatic (poor absorption),
  • 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 are recommended by the AASLD regardless of bleeding. Pre-procedurally the AGA has recommended >50.
• Appropriate DVT ppx should be given in most pts with few exceptions (plts <50k, active variceal hemorrhage)