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Zanetto A, Campello E, Senzolo M, Simioni P. The evolving knowledge on primary hemostasis in patients with cirrhosis: A comprehensive review. Hepatology 2024; 79:460-481. [PMID: 36825598 DOI: 10.1097/hep.0000000000000349] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
Patients with cirrhosis develop complex alterations in primary hemostasis that include both hypocoagulable and hypercoagulable features. This includes thrombocytopenia, multiple alterations of platelet function, and increased plasma levels of von Willebrand factor. Contrary to the historical view that platelet dysfunction in cirrhosis might be responsible for an increased bleeding tendency, the current theory posits a rebalanced hemostasis in patients with cirrhosis. Severe thrombocytopenia is not indicative of the bleeding risk in patients undergoing invasive procedures and does not dictate per se the need for pre-procedural prophylaxis. A more comprehensive and individualized risk assessment should combine hemostatic impairment, the severity of decompensation and systemic inflammation, and the presence of additional factors that may impair platelet function, such as acute kidney injury and bacterial infections. Although there are multiple, complex alterations of platelet function in cirrhosis, their net effect is not yet fully understood. More investigations evaluating the association between alterations of platelet function and bleeding/thrombosis may improve risk stratification in patients with decompensated cirrhosis. Besides hemostasis, the assessment of von Willebrand factor Ag and ADP-induced, whole-blood platelet aggregation normalized by platelet count (VITRO score and PLT ratio) are promising biomarkers to predict the risk of hepatic decompensation and survival in both compensated and decompensated patients. Further investigations into the in vivo interplay between platelets, circulating blood elements, and endothelial cells may help advance our understanding of cirrhotic coagulopathy. Here, we review the complex changes in platelets and primary hemostasis in cirrhosis and their potential clinical implications.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Paolo Simioni
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
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2
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Mohinani A, Patel S, Tan V, Kartika T, Olson S, DeLoughery TG, Shatzel J. Desmopressin as a hemostatic and blood sparing agent in bleeding disorders. Eur J Haematol 2023; 110:470-479. [PMID: 36656570 PMCID: PMC10073345 DOI: 10.1111/ejh.13930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Intranasal, subcutaneous, or intravenous desmopressin can be utilized to release von Willebrand Factor and Factor VIII into circulation, enhance platelet adhesion and shorten bleeding time. Due to these properties, desmopressin can be effective in controlling bleeding in mild hemophilia A, certain subtypes of von Willebrand disease and in acute bleeding from uremia, end stage renal disease, and liver disease. Its use, however, can be complicated by hyponatremia and rarely arterial thrombotic events. While desmopressin has also been used as a prophylactic blood sparing agent in orthopedic, renal, and hepatic procedures, clinical studies have shown limited benefit in these settings. The purpose of this article is to review the evidence for desmopressin in primary hematologic disorders, discuss its mechanism of action and evaluate its utility as a hemostatic and blood sparing product in various bleeding conditions.
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Affiliation(s)
- Ajay Mohinani
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Sarah Patel
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Virginia Tan
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas Kartika
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Sven Olson
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas G. DeLoughery
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph Shatzel
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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3
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Römer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kämmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent 2022; 8:20. [PMID: 35429255 PMCID: PMC9013394 DOI: 10.1186/s40729-022-00418-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 01/08/2023] Open
Abstract
Purpose Considering a high prevalence of congenital and especially acquired bleeding disorders, their heterogeneity and the multitude of possible treatments strategies, a review of the scientific data on this topic is needed to implement a treatment guide for healthcare professionals.
Methods A selective literature review was performed via PubMed for articles describing oral surgery / dental implant procedures in patients with congenital and acquired bleeding disorders. Out of the existing literature, potential treatment algorithms were extrapolated. Results In order to assess the susceptibility to bleeding, risk stratification can be used for both congenital and acquired coagulation disorders. This risk stratification, together with an appropriate therapeutic pathway, allows for an adequate and individualized therapy for each patient. A central point is the close interdisciplinary cooperation with specialists. In addition to the discontinuation or replacement of existing treatment modalities, local hemostyptic measures are of primary importance. If local measures are not sufficient, systemically administered substances such as desmopressin and blood products have to be used. Conclusions Despite the limited evidence, a treatment guide could be developed by means of this narrative review to improve safety for patients and practitioners. Prospective randomized controlled trials are needed to allow the implementation of official evidence-based guidelines.
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4
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Northup PG, Lisman T, Roberts LN. Treatment of bleeding in patients with liver disease. J Thromb Haemost 2021; 19:1644-1652. [PMID: 33974330 PMCID: PMC8362012 DOI: 10.1111/jth.15364] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/16/2021] [Accepted: 05/06/2021] [Indexed: 12/14/2022]
Abstract
Patients with cirrhosis frequently have complex alterations in their hemostatic system. Although routine diagnostic tests of hemostasis in cirrhosis (platelet count, prothrombin time, fibrinogen level) are suggestive of a bleeding tendency, it is now widely accepted that these tests do not reflect hemostatic competence in this population. Rather, patients with cirrhosis appear to have a rebalanced hemostatic system with hypercoagulable elements. Therefore, routine correction of hemostasis laboratory values, for example by fresh frozen plasma or platelet concentrates, with the aim to avoid spontaneous or procedure-related bleeding is not indicated as is outlined in recent clinical guidance documents. However, little guidance on how to manage patients with cirrhosis that are actively bleeding is available. Here we present three common bleeding scenarios, variceal bleeding, post-procedural bleeding and bleeding in a critically ill cirrhosis patient, with specific management suggestions. As patients with cirrhosis generally have adequate hemostatic competence and as bleeding complications may be unrelated to hemostatic failure, prohemostatic therapy is not the first line of management in bleeding patients with cirrhosis, even in the presence of markedly abnormal platelet counts and/or prothrombin times. We provide a rationale for the restrictive approach to prohemostatic therapy in bleeding patients with cirrhosis.
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Affiliation(s)
- Patrick G. Northup
- Center for the Study of Hemostasis and Coagulation in Liver DiseaseDivision of Gastroenterology and HepatologyUniversity of VirginiaCharlottesvilleVAUSA
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Lara N. Roberts
- Department of Haematological MedicineKing’s Thrombosis CentreKing’s College Hospital National Health Service (NHS) Foundation TrustLondonUK
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5
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Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, Lisman T, Valla DC. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:366-413. [PMID: 33219529 DOI: 10.1002/hep.31646] [Citation(s) in RCA: 285] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, CT.,Veterans Administration Healthcare System, West Haven, CT
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Riccardo A Superina
- Department of Transplant Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Dominique C Valla
- Hepatology Service, Hospital Beaujon, Clichy, France.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
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6
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Primary Hemostasis in Chronic Liver Disease and Cirrhosis: What Did We Learn over the Past Decade? Int J Mol Sci 2020; 21:ijms21093294. [PMID: 32384725 PMCID: PMC7247544 DOI: 10.3390/ijms21093294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/21/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023] Open
Abstract
Changes in primary hemostasis have been described in patients with chronic liver disease (CLD) and cirrhosis and are still subject to ongoing debate. Thrombocytopenia is common and multifactorial. Numerous studies also reported platelet dysfunction. In spite of these changes, primary hemostasis seems to be balanced. Patients with CLD and cirrhosis can suffer from both hemorrhagic and thrombotic complications. Variceal bleeding is the major hemorrhagic complication and is mainly determined by high portal pressure. Non portal hypertension-related bleeding due to hemostatic failure is uncommon. Thrombocytopenia can complicate management of invasive procedures in CLD patients. Recently, oral thrombopoietin agonists have been approved to raise platelets before invasive procedures. In this review we aim to bundle literature, published over the past decade, discussing primary hemostasis in CLD and cirrhosis including (1) platelet count and the role of thrombopoietin (TPO) agonists, (2) platelet function tests and markers of platelet activation, (3) von Willebrand factor and (4) global hemostasis tests.
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7
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Newland A, Bentley R, Jakubowska A, Liebman H, Lorens J, Peck-Radosavljevic M, Taieb V, Takami A, Tateishi R, Younossi ZM. A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia. ACTA ACUST UNITED AC 2020; 24:679-719. [PMID: 31581933 DOI: 10.1080/16078454.2019.1662200] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.
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Affiliation(s)
- Adrian Newland
- Barts Health National Health Service (NHS) Trust , London , UK
| | | | | | - Howard Liebman
- Jane Anne Nohl Division of Hematology, USC Norris Cancer Hospital , Los Angeles , CA , USA
| | | | - Markus Peck-Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt , Klagenfurt , Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna , Vienna , Austria
| | | | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine , Nagakute , Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital , Falls Church , VA , USA
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8
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Lange NW, Salerno DM, Berger K, Cushing MM, Brown RS. Management of Hepatic Coagulopathy in Bleeding and Nonbleeding Patients: An Evidence-Based Review. J Intensive Care Med 2020; 36:524-541. [PMID: 32079443 DOI: 10.1177/0885066620903027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with varying degrees of hepatic dysfunction often present with presumed bleeding diathesis based on interpretation of routine measures of coagulation (prothrombin time [PT], international normalized ratio [INR], and activated partial thromboplastin time). However, standard markers of coagulation do not reflect the actual bleeding risk in this population and may lead to inappropriate administration of hemostatic agents and blood products. The concept of "rebalanced hemostasis" explains both the risk of bleeding and clotting seen in patients with liver dysfunction. The role of pharmacologic agents and blood products for prevention of bleeding during high-risk procedures and treatment of clinically significant bleeding remains unclear. Viscoelastic measurements of the clotting cascade provide information about platelets, fibrinogen/fibrin polymerization, coagulation factors, and fibrinolysis that might better represent hemostasis in vivo and may better inform management strategies. Due to the paucity of available data, firm recommendations for the use of blood products and pharmacologic agents in patients with hepatic coagulopathies are lacking, and thus, these products should not be routinely administered. Traditional laboratory tests such as PT/INR should not be the sole determinant of potential interventions. Rather, clinicians should assess factors such as the severity of bleed or bleeding risk of the procedure, the patient's risk of thromboembolism, and the strength of available evidence for specific agents and blood products to guide decision-making.
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Affiliation(s)
- Nicholas W Lange
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - David M Salerno
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, 159947Weill Cornell Medicine, New York, NY, USA
- Department of Anesthesiology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology, Department of Medicine, 159947Weill Cornell Medicine, New York, NY, USA
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9
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Nilles KM, Caldwell SH, Flamm SL. Thrombocytopenia and Procedural Prophylaxis in the Era of Thrombopoietin Receptor Agonists. Hepatol Commun 2019; 3:1423-1434. [PMID: 31701067 PMCID: PMC6824078 DOI: 10.1002/hep4.1423] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/10/2019] [Indexed: 02/06/2023] Open
Abstract
Thrombocytopenia is common in patients with advanced liver disease. These patients frequently require invasive diagnostic or therapeutic procedures in the setting of thrombocytopenia. A common platelet goal before such procedures is ≥50,000/μL, but target levels vary by provider and the procedure. Platelet transfusion has disadvantages, including safety and cost. No other short‐term options for ameliorating thrombocytopenia before procedures were available until the thrombopoietin receptor agonists were recently approved. Avatrombopag and lusutrombopag can be used in certain patients with thrombocytopenia due to advanced liver disease undergoing elective invasive procedures; these new agents are highly effective in carefully selected patients, and real world data of safety and efficacy are awaited. TPO receptor agonists are an exciting new development that can raise platelet counts in liver patients with thrombocytopenia before elective procedures. We review the strategies to address peri‐procedure thrombocytopenia including data on the most recent trials involving TPO receptor agonists.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology Comprehensive Transplant Center Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology Department of Medicine Center for Coagulation in Liver Disease University of Virginia School of Medicine Charlottesville VA
| | - Steven L Flamm
- Division of Gastroenterology and Hepatology Comprehensive Transplant Center Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
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10
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Efeoğlu C, Sipahi Çalış A, Karasu Z, Koca H, Boyacıoğlu H. Prospective randomized single-blind study of post-operative bleeding after minor oral surgery in patients with cirrhosis. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:171-176. [PMID: 30457557 DOI: 10.5152/tjg.2018.18078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIMS The management of patients with cirrhosis requiring dental extractions is complicated due to an increased risk of post-operative bleeding. Topical hemostatic agents are usually required to control bleeding in these cases, as an adjunct to systemic measures of hemostasis. The aims of this randomized, prospective, single-blind clinical study are twofold. The primary aim is to compare the hemostatic efficacy of chitosan and surgicel in patients with cirrhosis after a tooth extraction, and the secondary aim is to assess the value of the current setting as a clinical model of post-operative bleeding following minor oral surgery. MATERIAL AND METHODS Fifty patients with cirrhosis scheduled for a tooth extraction under local anesthesia were prospectively included in the study in a randomized fashion. Patients were blinded to the treatment group they were in. The cirrhosis classification, bleeding time, trauma score, and corrected bleeding time (during post-operative reviews) were recorded. Statistical evaluations were done. RESULTS Study groups had an equal number of teeth extractions (40 teeth each). There were no statistically significant differences between the groups with respect to patient demographics, cirrhosis classification, trauma score, and bleeding time. No side effects were noted. CONCLUSION Both Celox and Surgicel are effective for controlling bleeding and are safe after a tooth extraction in patients with cirrhosis.
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Affiliation(s)
- Candan Efeoğlu
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Aylin Sipahi Çalış
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Zeki Karasu
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Hüseyin Koca
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Hayal Boyacıoğlu
- Department of Statistics, Ege University School of Science, İzmir, Turkey
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11
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Biancofiore G, Blasi A, De Boer MT, Franchini M, Hartmann M, Lisman T, Liumbruno GM, Porte RJ, Saner F, Senzolo M, Werner MJ. Perioperative hemostatic management in the cirrhotic patient: a position paper on behalf of the Liver Intensive Care Group of Europe (LICAGE). Minerva Anestesiol 2019; 85:782-798. [PMID: 30945514 DOI: 10.23736/s0375-9393.19.13468-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent data demonstrated that amongst patients undergoing elective surgery the prevalence of cirrhosis is 0.8% equating to approximately 25 million cirrhotic patients undergoing surgery each year worldwide. Overall, the presence of cirrhosis is independently associated with 47% increased risk of postoperative complications and over two and a half-increased risk of in-hospital mortality in patients undergoing elective surgery. In particular, perioperative patients with chronic liver disease have long been assumed to have a major bleeding risk on the basis of abnormal results for standard tests of hemostasis. However, recent evidence outlined significant changes to traditional knowledge and beliefs and, nowadays, with more sophisticated laboratory tests, it has been shown that patients with chronic liver disease may be in hemostatic balance as a result of concomitant changes in both pro- and antihemostatic pathways. The aim of this paper endorsed by the Liver Intensive Care Group of Europe was to provide an up-to-date overview of coagulation management in perioperative patients with chronic liver disease focusing on patient blood management, monitoring of hemostasis, and current role of hemostatic agents.
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Affiliation(s)
- Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy -
| | - Annabel Blasi
- Department of Anesthesia, Hospital Clinic, Barcelona, Spain
| | - Marieke T De Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Hospital of Mantua, Mantua, Italy
| | - Matthias Hartmann
- Department of Anesthesiology and Critical Care, University of Duisburg-Essen, Duisburg, Germany
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Fuat Saner
- Department of General-, Visceral- and Transplant Surgery, University Duisburg-Essen, Duisburg, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Maureen J Werner
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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12
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Nagrebetsky A, Al-Samkari H, Davis N, Kuter D, Wiener-Kronish J. Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. Br J Anaesth 2019; 122:19-31. [DOI: 10.1016/j.bja.2018.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 01/19/2023] Open
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13
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Efeoğlu C, Sipahi Çalış A, Karasu Z, Koca H, Boyacıoğlu H. Prospective randomized single-blind study of post-operative bleeding after minor oral surgery in patients with cirrhosis. TURKISH JOURNAL OF GASTROENTEROLOGY 2018. [PMID: 30457557 DOI: 10.5152/tjg.2018.18078.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS The management of patients with cirrhosis requiring dental extractions is complicated due to an increased risk of post-operative bleeding. Topical hemostatic agents are usually required to control bleeding in these cases, as an adjunct to systemic measures of hemostasis. The aims of this randomized, prospective, single-blind clinical study are twofold. The primary aim is to compare the hemostatic efficacy of chitosan and surgicel in patients with cirrhosis after a tooth extraction, and the secondary aim is to assess the value of the current setting as a clinical model of post-operative bleeding following minor oral surgery. MATERIAL AND METHODS Fifty patients with cirrhosis scheduled for a tooth extraction under local anesthesia were prospectively included in the study in a randomized fashion. Patients were blinded to the treatment group they were in. The cirrhosis classification, bleeding time, trauma score, and corrected bleeding time (during post-operative reviews) were recorded. Statistical evaluations were done. RESULTS Study groups had an equal number of teeth extractions (40 teeth each). There were no statistically significant differences between the groups with respect to patient demographics, cirrhosis classification, trauma score, and bleeding time. No side effects were noted. CONCLUSION Both Celox and Surgicel are effective for controlling bleeding and are safe after a tooth extraction in patients with cirrhosis.
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Affiliation(s)
- Candan Efeoğlu
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Aylin Sipahi Çalış
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Zeki Karasu
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Hüseyin Koca
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Hayal Boyacıoğlu
- Department of Statistics, Ege University School of Science, İzmir, Turkey
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14
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Estcourt LJ, Malouf R, Doree C, Trivella M, Hopewell S, Birchall J. Prophylactic platelet transfusions prior to surgery for people with a low platelet count. Cochrane Database Syst Rev 2018; 9:CD012779. [PMID: 30221749 PMCID: PMC6513131 DOI: 10.1002/14651858.cd012779.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND People with thrombocytopenia often require a surgical procedure. A low platelet count is a relative contraindication to surgery due to the risk of bleeding. Platelet transfusions are used in clinical practice to prevent and treat bleeding in people with thrombocytopenia. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to surgery. Alternatives to platelet transfusion are also used prior surgery. OBJECTIVES To determine the clinical effectiveness and safety of prophylactic platelet transfusions prior to surgery for people with a low platelet count. SEARCH METHODS We searched the following major data bases: Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), PubMed (e-publications only), Ovid MEDLINE, Ovid Embase, the Transfusion Evidence Library and ongoing trial databases to 11 December 2017. SELECTION CRITERIA We included all randomised controlled trials (RCTs), as well as non-RCTs and controlled before-and-after studies (CBAs), that met Cochrane EPOC (Effective Practice and Organisation of Care) criteria, that involved the transfusion of platelets prior to surgery (any dose, at any time, single or multiple) in people with low platelet counts. We excluded studies on people with a low platelet count who were actively bleeding. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane for data collection. We were only able to combine data for two outcomes and we presented the rest of the findings in a narrative form. MAIN RESULTS We identified five RCTs, all conducted in adults; there were no eligible non-randomised studies. Three completed trials enrolled 180 adults and two ongoing trials aim to include 627 participants. The completed trials were conducted between 2005 and 2009. The two ongoing trials are scheduled to complete recruitment by October 2019. One trial compared prophylactic platelet transfusions to no transfusion in people with thrombocytopenia in an intensive care unit (ICU). Two small trials, 108 participants, compared prophylactic platelet transfusions to other alternative treatments in people with liver disease. One trial compared desmopressin to fresh frozen plasma or one unit of platelet transfusion or both prior to surgery. The second trial compared platelet transfusion prior to surgery with two types of thrombopoietin mimetics: romiplostim and eltrombopag. None of the included trials were free from methodological bias. No included trials compared different platelet count thresholds for administering a prophylactic platelet transfusion prior to surgery. None of the included trials reported on all the review outcomes and the overall quality per reported outcome was very low.None of the three completed trials reported: all-cause mortality at 90 days post surgery; mortality secondary to bleeding, thromboembolism or infection; number of red cell or platelet transfusions per participant; length of hospital stay; or quality of life.None of the trials included children or people who needed major surgery or emergency surgical procedures.Platelet transfusion versus no platelet transfusion (1 trial, 72 participants)We were very uncertain whether giving a platelet transfusion prior to surgery had any effect on all-cause mortality within 30 days (1 trial, 72 participants; risk ratio (RR) 0.78, 95% confidence interval (CI) 0.41 to 1.45; very-low quality evidence). We were very uncertain whether giving a platelet transfusion prior to surgery had any effect on the risk of major (1 trial, 64 participants; RR 1.60, 95% CI 0.29 to 8.92; very low-quality evidence), or minor bleeding (1 trial, 64 participants; RR 1.29, 95% CI 0.90 to 1.85; very-low quality evidence). No serious adverse events occurred in either study arm (1 trial, 72 participants, very low-quality evidence).Platelet transfusion versus alternative to platelet transfusion (2 trials, 108 participants)We were very uncertain whether giving a platelet transfusion prior to surgery compared to an alternative has any effect on the risk of major (2 trials, 108 participants; no events; very low-quality evidence), or minor bleeding (desmopressin: 1 trial, 36 participants; RR 0.89, 95% CI 0.06 to 13.23; very-low quality evidence: thrombopoietin mimetics: 1 trial, 65 participants; no events; very-low quality evidence). We were very uncertain whether there was a difference in transfusion-related adverse effects between the platelet transfused group and the alternative treatment group (desmopressin: 1 trial, 36 participants; RR 2.70, 95% CI 0.12 to 62.17; very-low quality evidence). AUTHORS' CONCLUSIONS Findings of this review were based on three small trials involving minor surgery in adults with thrombocytopenia. We found insufficient evidence to recommend the administration of preprocedure prophylactic platelet transfusions in this situation with a lack of evidence that transfusion resulted in a reduction in postoperative bleeding or all-cause mortality. The small number of trials meeting the inclusion criteria and the limitation in reported outcomes across the trials precluded meta-analysis for most outcomes. Further adequately powered trials, in people of all ages, of prophylactic platelet transfusions compared with no transfusion, other alternative treatments, and considering different platelet thresholds prior to planned and emergency surgical procedures are required. Future trials should include major surgery and report on bleeding, adverse effects, mortality (as a long-term outcome) after surgery, duration of hospital stay and quality of life measures.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Janet Birchall
- NHS Blood and Transplant, Bristol and North Bristol NHS TrustHaematology/Transfusion MedicineBristolUK
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Abuelkasem E, Tanaka KA, Planinsic RM. Recent update on coagulation management and hemostatic therapies in liver transplantation. Minerva Anestesiol 2018; 84:1070-1080. [DOI: 10.23736/s0375-9393.18.12487-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
BACKGROUND Liver transplantation has become commonplace for patients with end-stage liver disease. The liver is a bodily organ of great importance, and its dysfunction can cause significant complications throughout the body. Patients with hepatic disease should be able to acquire knowledge of the physiology of the liver via the dental profession, and it is also necessary to modify some aspects of dental treatment even in healthy patients. Problems such as excessive bleeding and hepatotoxicity caused by some of the drugs used in dental treatment can lead to a decrease in systemic health. Otherwise, patients with liver disease will have poorer oral health than the general population. Thus, it is important to have well-established routine dental care in this patient group and offer management of oral health in view of the effects of liver disease. METHODS The objective of this work was to undertake a bibliographic review of the dental approaches to patients with liver disease and liver transplant recipients and to propose a dental care routine for such patients in an outpatient setting. RESULTS A search was carried out on the main scientific databases (PubMed, Medline, and SciELO) for publications related to this subject and, particularly those published after 2010. The articles selected describe poor oral hygiene among patients, independent of the etiology of their liver disease. These patients also had a high index of xerostomia, caries, periodontal disease, apical lesions, and fungical infections. To control bleeding during and after surgery, hemostatic measures must be understood and adopted. CONCLUSION There are no data about routine dental care among liver disease/transplantation patients. Thus, our findings will hopefully encourage other services to structure their approaches and consider enhancing their dental care protocols for patients with liver-related complications.
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Kumbargere Nagraj S, Prashanti E, Aggarwal H, Lingappa A, Muthu MS, Kiran Kumar Krishanappa S, Hassan H. Interventions for treating post-extraction bleeding. Cochrane Database Syst Rev 2018; 3:CD011930. [PMID: 29502332 PMCID: PMC6494262 DOI: 10.1002/14651858.cd011930.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. This is an update of a review published in June 2016. OBJECTIVES To assess the effects of interventions for treating different types of post-extraction bleeding. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 24 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 24 January 2018), Embase Ovid (1 May 2015 to 24 January 2018) and CINAHL EBSCO (1937 to 24 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We searched the reference lists of relevant systematic reviews. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment. DATA COLLECTION AND ANALYSIS Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis. MAIN RESULTS We did not find any randomised controlled trial suitable for inclusion in this review. AUTHORS' CONCLUSIONS We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).
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Affiliation(s)
- Sumanth Kumbargere Nagraj
- Faculty of Dentistry, Melaka‐Manipal Medical College, Manipal Academy of Higher Education (MAHE), ManipalDepartment of Oral Medicine and Oral RadiologyJalan Batu HamparBukit BaruMelakaMalaysia75150
| | - Eachempati Prashanti
- Faculty of Dentistry, Melaka‐Manipal Medical College, (Manipal Academy of Higher Education)Department of ProsthodonticsJalan Batu HamparBukit BaruMelakaMalaysia75150
| | - Himanshi Aggarwal
- King George's Medical UniversityDepartment of ProsthodonticsKGMU CampusLucknowUttar PradeshIndia
| | - Ashok Lingappa
- Bapuji Dental College and HospitalOral Medicine & RadiologyDavangereKarnatakaIndia
| | - Murugan S Muthu
- Faculty of Dental Sciences, Sri Ramachandra UniversityPaediatric Dentistry2C Akme Park, Pedo PlanetPaediatric Dental Centre, OPP S&S POWER LTD,PorurChennaiIndia600116
| | - Salian Kiran Kumar Krishanappa
- Faculty of Dentistry, Melaka Manipal Medical College (Manipal Academy of Higher Education)Department of ProsthodonticsJalan Batu HamparMelakaMalaysia75150
| | - Haszelini Hassan
- International Islamic University MalaysiaDepartment of Oral Maxillofacial Surgery & Oral Diagnosis, Kulliyyah of DentistryKuala LumpurMalaysia
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Desborough MJ, Oakland K, Brierley C, Bennett S, Doree C, Trivella M, Hopewell S, Stanworth SJ, Estcourt LJ. Desmopressin use for minimising perioperative blood transfusion. Cochrane Database Syst Rev 2017; 7:CD001884. [PMID: 28691229 PMCID: PMC5546394 DOI: 10.1002/14651858.cd001884.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Blood transfusion is administered during many types of surgery, but its efficacy and safety are increasingly questioned. Evaluation of the efficacy of agents, such as desmopressin (DDAVP; 1-deamino-8-D-arginine-vasopressin), that may reduce perioperative blood loss is needed. OBJECTIVES To examine the evidence for the efficacy of DDAVP in reducing perioperative blood loss and the need for red cell transfusion in people who do not have inherited bleeding disorders. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2017, issue 3) in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1937), the Transfusion Evidence Library (from 1980), and ongoing trial databases (all searches to 3 April 2017). SELECTION CRITERIA We included randomised controlled trials comparing DDAVP to placebo or an active comparator (e.g. tranexamic acid, aprotinin) before, during, or immediately after surgery or after invasive procedures in adults or children. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 65 completed trials (3874 participants) and four ongoing trials. Of the 65 completed trials, 39 focused on adult cardiac surgery, three on paediatric cardiac surgery, 12 on orthopaedic surgery, two on plastic surgery, and two on vascular surgery; seven studies were conducted in surgery for other conditions. These trials were conducted between 1986 and 2016, and 11 were funded by pharmaceutical companies or by a party with a commercial interest in the outcome of the trial.The GRADE quality of evidence was very low to moderate across all outcomes. No trial reported quality of life. DDAVP versus placebo or no treatmentTrial results showed considerable heterogeneity between surgical settings for total volume of red cells transfused (low-quality evidence) and for total blood loss (very low-quality evidence) due to large differences in baseline blood loss. Consequently, these outcomes were not pooled and were reported in subgroups.Compared with placebo, DDAVP may slightly decrease the total volume of red cells transfused in adult cardiac surgery (mean difference (MD) -0.52 units, 95% confidence interval (CI) -0.96 to -0.08 units; 14 trials, 957 participants), but may lead to little or no difference in orthopaedic surgery (MD -0.02, 95% CI -0.67 to 0.64 units; 6 trials, 303 participants), vascular surgery (MD 0.06, 95% CI -0.60 to 0.73 units; 2 trials, 135 participants), or hepatic surgery (MD -0.47, 95% CI -1.27 to 0.33 units; 1 trial, 59 participants).DDAVP probably leads to little or no difference in the total number of participants transfused with blood (risk ratio (RR) 0.96, 95% CI 0.86 to 1.06; 25 trials; 1806 participants) (moderate-quality evidence).Whether DDAVP decreases total blood loss in adult cardiac surgery (MD -135.24 mL, 95% CI -210.80 mL to -59.68 mL; 22 trials, 1358 participants), orthopaedic surgery (MD -285.76 mL, 95% CI -514.99 mL to -56.53 mL; 5 trials, 241 participants), or vascular surgery (MD -582.00 mL, 95% CI -1264.07 mL to 100.07 mL; 1 trial, 44 participants) is uncertain because the quality of evidence is very low.DDAVP probably leads to little or no difference in all-cause mortality (Peto odds ratio (pOR) 1.09, 95% CI 0.51 to 2.34; 22 trials, 1631 participants) or in thrombotic events (pOR 1.36, 95% CI, 0.85 to 2.16; 29 trials, 1984 participants) (both low-quality evidence). DDAVP versus placebo or no treatment for people with platelet dysfunctionCompared with placebo, DDAVP may lead to a reduction in the total volume of red cells transfused (MD -0.65 units, 95% CI -1.16 to -0.13 units; 6 trials, 388 participants) (low-quality evidence) and in total blood loss (MD -253.93 mL, 95% CI -408.01 mL to -99.85 mL; 7 trials, 422 participants) (low-quality evidence).DDAVP probably leads to little or no difference in the total number of participants receiving a red cell transfusion (RR 0.83, 95% CI 0.66 to 1.04; 5 trials, 258 participants) (moderate-quality evidence).Whether DDAVP leads to a difference in all-cause mortality (pOR 0.72, 95% CI 0.12 to 4.22; 7 trials; 422 participants) or in thrombotic events (pOR 1.58, 95% CI 0.60 to 4.17; 7 trials, 422 participants) is uncertain because the quality of evidence is very low. DDAVP versus tranexamic acidCompared with tranexamic acid, DDAVP may increase the volume of blood transfused (MD 0.6 units, 95% CI 0.09 to 1.11 units; 1 trial, 40 participants) and total blood loss (MD 142.81 mL, 95% CI 79.78 mL to 205.84 mL; 2 trials, 115 participants) (both low-quality evidence).Whether DDAVP increases or decreases the total number of participants transfused with blood is uncertain because the quality of evidence is very low (RR 2.42, 95% CI 1.04 to 5.64; 3 trials, 135 participants).No trial reported all-cause mortality.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 2.92, 95% CI 0.32 to 26.83; 2 trials, 115 participants). DDAVP versus aprotininCompared with aprotinin, DDAVP probably increases the total number of participants transfused with blood (RR 2.41, 95% CI 1.45 to 4.02; 1 trial, 99 participants) (moderate-quality evidence).No trials reported volume of blood transfused or total blood loss and the single trial that included mortality as an outcome reported no deaths.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 0.98, 95% CI 0.06 to 15.89; 2 trials, 152 participants). AUTHORS' CONCLUSIONS Most of the evidence derived by comparing DDAVP versus placebo was obtained in cardiac surgery, where DDAVP was administered after cardiopulmonary bypass. In adults undergoing cardiac surgery, the reduction in volume of red cells transfused and total blood loss was small and was unlikely to be clinically important. It is less clear whether DDAVP may be of benefit for children and for those undergoing non-cardiac surgery. A key area for researchers is examining the effects of DDAVP for people with platelet dysfunction. Few trials have compared DDAVP versus tranexamic acid or aprotinin; consequently, we are uncertain of the relative efficacy of these interventions.
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Affiliation(s)
| | - Kathryn Oakland
- NHS Blood and TransplantHaematology/Transfusion MedicineOxfordUK
| | - Charlotte Brierley
- John Radcliffe HospitalDepartment of HaematologyHeadley WayOxfordUKOX3 9DU
| | - Sean Bennett
- University of OttawaDepartment of Surgery501 Smyth RoadOttawaOntarioCanadaK1M 1R4
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineOxfordUK
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Desborough MJR, Smethurst PA, Estcourt LJ, Stanworth SJ. Alternatives to allogeneic platelet transfusion. Br J Haematol 2016; 175:381-392. [PMID: 27650431 DOI: 10.1111/bjh.14338] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Allogeneic platelet transfusions are widely used for the prevention and treatment of bleeding in thrombocytopenia. Recent evidence suggests platelet transfusions have limited efficacy and are associated with uncertain immunomodulatory risks and concerns about viral or bacterial transmission. Alternatives to transfusion are a well-recognised tenet of Patient Blood Management, but there has been less focus on different strategies to reduce bleeding risk by comparison to platelet transfusion. Direct alternatives to platelet transfusion include agents to stimulate endogenous platelet production (thrombopoietin mimetics), optimising platelet adhesion to endothelium by treating anaemia or increasing von Willebrand factor levels (desmopressin), increasing formation of cross-linked fibrinogen (activated recombinant factor VII, fibrinogen concentrate or recombinant factor XIII), decreasing fibrinolysis (tranexamic acid or epsilon aminocaproic acid) or using artificial or modified platelets (cryopreserved platelets, lyophilised platelets, haemostatic particles, liposomes, engineered nanoparticles or infusible platelet membranes). The evidence base to support the use of these alternatives is variable, but an area of active research. Much of the current randomised controlled trial focus is on evaluation of the use of thrombopoietin mimetics and anti-fibrinolytics. It is also recognised that one alternative strategy to platelet transfusion is choosing not to transfuse at all.
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Affiliation(s)
- Michael J R Desborough
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK. .,Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK.
| | | | - Lise J Estcourt
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Simon J Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
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Sumanth KN, Prashanti E, Aggarwal H, Kumar P, Lingappa A, Muthu MS, Kiran Kumar Krishanappa S. Interventions for treating post-extraction bleeding. Cochrane Database Syst Rev 2016:CD011930. [PMID: 27285450 DOI: 10.1002/14651858.cd011930.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. OBJECTIVES To assess the effects of interventions for treating different types of post-extraction bleeding. SEARCH METHODS We searched the following electronic databases: The Cochrane Oral Health Group Trials Register (to 22 March 2016); The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, Issue 2); MEDLINE via OVID (1946 to 22 March 2016); CINAHL via EBSCO (1937 to 22 March 2016). Due to the ongoing Cochrane project to search EMBASE and add retrieved clinical trials to CENTRAL, we searched only the last 11 months of EMBASE via OVID (1 May 2015 to 22 March 2016). We placed no further restrictions on the language or date of publication. We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov), and the WHO Clinical Trials Registry Platform for ongoing trials (http://apps.who.int/trialsearch/default.aspx). We also checked the reference lists of excluded trials. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment. DATA COLLECTION AND ANALYSIS Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis. MAIN RESULTS We did not find any randomised controlled trial suitable for inclusion in this review. AUTHORS' CONCLUSIONS We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).
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Affiliation(s)
- Kumbargere N Sumanth
- Department of Oral Medicine & Oral Radiology, Faculty of Dentistry, Melaka-Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka, Malaysia, 75150
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Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48:455-467. [PMID: 27012444 DOI: 10.1016/j.dld.2016.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.
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Helenius-Hietala J, Åberg F, Meurman JH, Nordin A, Isoniemi H. Oral surgery in liver transplant candidates: a retrospective study on delayed bleeding and other complications. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 121:490-5. [DOI: 10.1016/j.oooo.2016.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 01/18/2016] [Accepted: 01/24/2016] [Indexed: 02/07/2023]
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Abstract
Liver failure can be categorized into acute liver failure, chronic liver failure and acute decompensation of chronic liver failure, the so-called acute-on-chronic liver failure, the incidence of which has increased over the last few years. Liver failure leads to a variety of pathophysiological changes where the extent is dependent on the nature and duration of the liver disease. This includes restriction of synthesis and metabolism, such as coagulation defects. Especially chronic liver failure is associated with malfunction of extrahepatic organs, such as the cardiovascular system, the respiratory system and the kidneys. In addition to these pathophysiological alterations the Child-Turcotte-Pugh classification (CTP) and the model of end stage liver disease (MELD) are used for perioperative risk stratification.
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Affiliation(s)
- Eva-Lotte Camboni-Schellenberg
- Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Deutschland
| | - Barbara Sinner
- Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Deutschland.
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Patel S, Perry MM, Spolarich AE. Oral surgery in a patient with cirrhosis and thrombocytopenia: a case report. SPECIAL CARE IN DENTISTRY 2015; 36:93-8. [PMID: 26625941 DOI: 10.1111/scd.12150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE While most oral surgical procedures can be safely performed in an outpatient setting, certain medical conditions may present a higher chance of postoperative complications. In particular, those predisposing the patient to bleeding abnormalities pose a potential risk when performing such treatments. The authors report a case involving full-mouth extractions in a patient with cirrhosis and thrombocytopenia after obtaining a platelet transfusion. METHODS/CASE A 62-year-old Caucasian female presented to a university special care dental clinic requiring extractions. Her pertinent medical history was remarkable for cirrhosis and thrombocytopenia, with a platelet count of 32,000/uL. Upon medical consultation, the patient was appointed for a prophylactic platelet transfusion. The surgery was rendered uneventfully, and the patient achieved adequate hemostasis without hospitalization. CONCLUSION/CLINICAL RELEVANCE Patients with cirrhosis pose a potential bleeding risk with dental surgical procedures. Pre-operative medical consultation, review of pertinent laboratory values, and prophylactic platelet transfusion allow these patients to be managed safely in an outpatient setting.
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Affiliation(s)
- Seena Patel
- Associate Director of Oral Medicine, Arizona School of Dentistry and Oral Health, A.T. Still University, Mesa, Arizona
| | - Maureen Munnelly Perry
- Associate Dean for Post-Doctoral Education, Director, The Center for Advanced Oral Health, Associate Professor & Director, Special Care Dentistry, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona.,Associate Director, Central Arizona Region, NYU Lutheran Medical Center, Advanced Education in General Dentistry Program, Mesa, Arizona
| | - Ann Eshenaur Spolarich
- Professor and Director of Research, Arizona School of Dentistry and Oral Health, A.T. Still University, Mesa, Arizona
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27
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Rodríguez Martínez S, Talaván Serna J, Silvestre FJ. [Dental management in patients with cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 39:224-32. [PMID: 26541210 DOI: 10.1016/j.gastrohep.2015.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 07/14/2015] [Accepted: 07/27/2015] [Indexed: 01/03/2023]
Abstract
The present article makes a brief review about dental management of the patients with cirrhosis. It focus on problems related with infections, haemorrhagic events and treatment with drugs of common use in odontology.
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Affiliation(s)
| | - Julio Talaván Serna
- Servicio de Anestesiología y Reanimación, Hospital General d́Ontinyent, Valencia, España
| | - Francisco-Javier Silvestre
- Departamento de Estomatología, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España
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28
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Sumanth KN, Prashanti E, Aggarwal H, Kumar P, Kiran Kumar Krishanappa S. Interventions for managing post-extraction bleeding. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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29
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Arshad F, Stoof SCM, Leebeek FWG, Ruitenbeek K, Adelmeijer J, Blokzijl H, van den Berg AP, Porte RJ, Kruip MJHA, Lisman T. Infusion of DDAVP does not improve primary hemostasis in patients with cirrhosis. Liver Int 2015; 35:1809-15. [PMID: 25522671 DOI: 10.1111/liv.12765] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 12/10/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Cirrhosis frequently affects multiple components of hemostasis. Reversal of the coagulopathy of these patients is frequently required in case of bleeding episodes, or as prophylaxis before invasive procedures. Although 1-deamino-8-D-arginine vasopressin (DDAVP) is widely used as a pro-hemostatic agent in patients with cirrhosis, it is unclear whether DDAVP truly enhances hemostasis in these patients. Here we investigated the hemostatic effects of a single bolus of DDAVP in patients with cirrhosis. METHODS Ten patients with cirrhosis (child B or C) and ten patients with mild haemophilia A received an intravenous single bolus of 0.3 microgram/kg DDAVP. Plasma was collected prior to and at 1, 3, 6, and 24 h after DDAVP administration. Levels of Von Willebrand factor (VWF), VWF propeptide, factor VIII (FVIII), and ADAMTS13 were measured in all plasma samples, whereas VWF multimers and functional VWF-dependent platelet adhesion were determined in the samples pre- and 1 h after DDAVP administration. RESULTS Following DDAVP administration, VWF, FVIII, and VWF propeptide levels increased in patients with haemophilia, while patients with cirrhosis only showed an increase in VWF propeptide and FVIII levels. High molecular weight VWF multimers and VWF-dependent platelet adhesion increased in patients with haemophilia one hour after DDAVP administration, but did not change in the patients with cirrhosis. Levels of ADAMTS13 were unaffected in both patient groups after DDAVP. CONCLUSION The lack of relevant effects of DDAVP on laboratory indices of primary hemostasis in patients with cirrhosis is in line with previous clinical study results in these patients.
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Affiliation(s)
- Freeha Arshad
- Surgical Research Laboratory, University Medical Center Groningen, Groningen, The Netherlands.,Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sara C M Stoof
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karin Ruitenbeek
- Surgical Research Laboratory, University Medical Center Groningen, Groningen, The Netherlands.,Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arie P van den Berg
- Department of Gastroenterology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, University Medical Center Groningen, Groningen, The Netherlands.,Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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30
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Abstract
Liver disease is characterized by changes in all phases of hemostasis. These hemostatic alterations were long considered to predispose patients with liver disease towards a bleeding tendency, as they are associated with prolonged conventional coagulation tests. However, these patients may also suffer from thrombotic complications, and we now know that the hemostatic system in patient with liver disease is, in fact, in a rebalanced state. In this review we discuss the concept of rebalanced hemostasis and its implications for clinical management of patients with liver disease. For instance, there is no evidence that the use of prophylactic blood product transfusion prior to invasive procedures reduces bleeding risk. Clinicians should also be aware of the possibility of thrombosis occurring in patients with a liver disease, and regular thrombosis prophylaxis should not be withheld in these patients.
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Affiliation(s)
- Wilma Potze
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, BA44, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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31
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Kujovich JL. Coagulopathy in liver disease: a balancing act. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:243-9. [PMID: 26637729 DOI: 10.1182/asheducation-2015.1.243] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Liver disease results in complex alterations of all 3 phases of hemostasis. It is now recognized that hemostasis is rebalanced in chronic liver disease. The fall in clotting factor levels is accompanied by a parallel fall in anticoagulant proteins. High von Willebrand factor levels counteract defects in primary hemostasis. Conventional coagulation tests do not fully reflect the derangement in hemostasis and do not accurately predict the risk of bleeding. Global coagulation assays (thrombin generation, thromboelastography) reflect the interaction between procoagulant factors, anticoagulant factors, platelets, and the fibrinolytic system and show promise for assessing bleeding risk and guiding therapy. These assays are not yet commercially approved or validated. Prevention of bleeding should not be aimed at correcting conventional coagulation tests. Thrombopoietin receptor agonists were shown to increase the platelet count in cirrhotic patients undergoing invasive procedures but may increase the risk of thrombosis. Rebalanced hemostasis in liver disease is precarious and may be tipped toward hemorrhage or thrombosis depending on coexisting circumstantial risk factors. Bacterial infection may impair hemostasis in cirrhosis by triggering the release of endogenous heparinoids. There are no evidence-based guidelines for hemostatic therapy of acute hemorrhage in liver disease. There is currently inadequate evidence to support the use of recombinant FVIIa, prothrombin complex concentrates, or tranexamic acid in acute variceal or other hemorrhage.
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Affiliation(s)
- Jody L Kujovich
- Oregon Health & Science University, Pediatric Hematology/Oncology, Oregon Hemophilia Center, Portland, OR
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32
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Givol N, Hirschhorn A, Lubetsky A, Bashari D, Kenet G. Oral surgery‐associated postoperative bleeding in haemophilia patients – a tertiary centre's two decade experience. Haemophilia 2014; 21:234-240. [DOI: 10.1111/hae.12573] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- N. Givol
- Unit of Oral and Maxillofacial Surgery Soroka University Medical Center Beer ShevaIsrael
| | - A. Hirschhorn
- Department of Oral and Maxillofacial SurgerySheba Medical Center Ramat Gan Israel
- Sackler Medical School Tel Aviv UniversityRamat GanIsrael
| | - A. Lubetsky
- Sackler Medical School Tel Aviv UniversityRamat GanIsrael
- National Hemophilia Center Sheba Medical Center Ramat Gan Israel
| | - D. Bashari
- Sackler Medical School Tel Aviv UniversityRamat GanIsrael
- National Hemophilia Center Sheba Medical Center Ramat Gan Israel
| | - G. Kenet
- Sackler Medical School Tel Aviv UniversityRamat GanIsrael
- National Hemophilia Center Sheba Medical Center Ramat Gan Israel
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Abstract
The complex nature of haemostasis in patients with liver disease can result in bleeding and/or thrombosis. These opposing outcomes, which have multiple contributing factors, can pose diagnostic and therapeutic dilemmas for physicians. With the high rate of haemorrhagic complications in patients with cirrhosis, we examine the various procoagulants available for use in this population. In this Review, we describe the clinical and current rationale for using each of the currently available procoagulants-vitamin K, fresh frozen plasma (FFP), cryoprecipitate, platelets, recombinant factor VIIa (rFVIIa), antifibrinolytics, prothrombin concentrate complexes (PCC), desmopressin and red blood cells. By examining the evidence and use of these agents in liver disease, we provide a framework for targeted, goal-directed therapy with procoagulants.
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Northup PG, Caldwell SH. Coagulation in liver disease: a guide for the clinician. Clin Gastroenterol Hepatol 2013; 11:1064-74. [PMID: 23506859 DOI: 10.1016/j.cgh.2013.02.026] [Citation(s) in RCA: 163] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/18/2013] [Accepted: 02/20/2013] [Indexed: 02/06/2023]
Abstract
The human hemostasis system is complex and poorly understood after decades of intense scientific study. Despite multiple defects in routine coagulation laboratory studies in patients with chronic liver disease, there is growing evidence that these patients are effectively "rebalanced" with regard to procoagulant and anticoagulant activity and that most of these patients remain in a tenuous but balanced state of hemostasis. A major difficulty in the assessment of these patients is that there are no established laboratory tests that accurately reflect the changes in both the procoagulant and anticoagulant systems; therefore, routine laboratory testing is misleading to the clinician and may prompt inappropriate or risky therapies with little real benefit to the patient. The international normalized ratio is an example of this type of misleading test. Although the international normalized ratio is inextricably linked to prognosis and severity of protein synthetic dysfunction in acute and chronic liver disease, it is a very poor marker for bleeding risk and should not be used in isolation for this purpose. Coagulation disorders are critical in the management of frequent clinical scenarios such as esophageal variceal bleeding, invasive and percutaneous procedures, portal vein thrombosis, venous thromboembolism, and acute liver failure. This article summarizes the pathophysiology of hemostasis in liver disease, describes the strengths and weaknesses of various laboratory tests in assessment of these patients, and outlines the optimal management of hemostasis for some common clinical scenarios. Further research is needed for proper understanding of hemostasis in liver disease to optimally and safely manage these complex patients.
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Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Coagulation in Liver Disease, University of Virginia, Charlottesville, Virginia, USA.
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35
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Muciño-Bermejo J, Carrillo-Esper R, Uribe M, Méndez-Sánchez N. Coagulation abnormalities in the cirrhotic patient. Ann Hepatol 2013. [DOI: 10.1016/s1665-2681(19)31312-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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36
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Ozier Y, Cadic A, Dovergne A. Prise en charge des troubles de l’hémostase chez l’insuffisant hépatique. Transfus Clin Biol 2013; 20:249-54. [DOI: 10.1016/j.tracli.2013.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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37
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Rai R, Nagral S, Nagral A. Surgery in a patient with liver disease. J Clin Exp Hepatol 2012; 2:238-46. [PMID: 25755440 PMCID: PMC3940091 DOI: 10.1016/j.jceh.2012.05.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 05/15/2012] [Indexed: 12/12/2022] Open
Abstract
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.
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Key Words
- ABG, arterial blood gas
- ASA, American Society of Anesthesiologists
- Anesthesia
- BNP, brain natriuretic peptide
- COPD, chronic obstructive pulmonary disease
- CTP, Child–Turcotte–Pugh
- CVP, central venous pressure
- Child–Pugh score
- FDP, fibrin degradation products
- FFP, fresh frozen plasma
- HPS, hepatopulmonary syndrome
- ICG, indocyanine green
- ICU, intensive care unit
- INR, international normalized ratio
- MELD, model for end-stage liver disease
- NSAID, nonsteroidal anti-inflammatory drug
- PICD, paracentesis-induced circulatory dysfunction
- PT, prothrombin time
- PTT, partial thromboplastin time
- SBP, spontaneous bacterial peritonitis
- TEG, thromboelastogram
- TIPS, transjugular intrahepatic portosystemic shunt
- cirrhosis
- coagulopathy
- hepatic
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Affiliation(s)
- Rakesh Rai
- Department of HPB Surgery and Liver Transplantation, Fortis Hospital, Mulund, Mumbai, India
| | - Sanjay Nagral
- Department of Surgical Gastroenterology, Jaslok Hospital, Mumbai, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, India,Address for correspondence: Aabha Nagral, Department of Gastroenterology, Jaslok Hospital, 7, Snehasagar, Prabhanagar, Prabhadevi, Mumbai - 400025, India.
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38
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GIVOL N, GOLDSTEIN G, PELEG O, SHENKMAN B, ZIMRAN A, ELSTEIN D, KENET G. Thrombocytopenia and bleeding in dental procedures of patients with Gaucher disease. Haemophilia 2011; 18:117-21. [DOI: 10.1111/j.1365-2516.2011.02540.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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