1
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Drolz A. [Bleeding in liver diseases]. Med Klin Intensivmed Notfmed 2024; 119:458-464. [PMID: 39138654 DOI: 10.1007/s00063-024-01167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024]
Abstract
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Affiliation(s)
- Andreas Drolz
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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2
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Kasper P, Tacke F, Michels G. [Coagulation disorders in liver cirrhosis - Diagnostics and management]. Dtsch Med Wochenschr 2024; 149:963-973. [PMID: 39094601 DOI: 10.1055/a-2330-3564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Patients with liver cirrhosis often exhibit complex alterations in their hemostatic system that can be associated with both bleeding and thrombotic complications. While prophylactic correction of abnormal coagulation parameters should be avoided, an individualized approach is recommended prior to invasive procedures, whereby specific preventive measures to stabilize hemostasis should be based on the periprocedural bleeding risk. While the haemostatic system of patients with compensated cirrhosis is often in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic factors, a decompensation of liver cirrhosis can lead to destabilization of this fragile equilibrium. Since conventional coagulation tests do not adequately capture the complex changes in the hemostatic system in cirrhosis, functional analysis methods such as viscoelastic tests or thrombin generation assays can be used for evaluating the coagulation status. This review describes the underlying pathophysiological changes in the hemostatic system in liver cirrhosis, provides an overview of diagnostic methods and discusses therapeutic measures in case of bleeding and thrombotic complications.
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Affiliation(s)
- Philipp Kasper
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Köln
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité Campus Mitte und Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin
| | - Guido Michels
- Notfallzentrum, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Trier, Deutschland
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3
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Li F, Wang T, Liang J, Qian B, Tang F, Gao Y, Lv J. Albumin‑bilirubin grade and INR for the prediction of esophagogastric variceal rebleeding after endoscopic treatment in cirrhosis. Exp Ther Med 2023; 26:501. [PMID: 37822588 PMCID: PMC10562956 DOI: 10.3892/etm.2023.12200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/18/2023] [Indexed: 10/13/2023] Open
Abstract
Rebleeding following endoscopic treatment in patients with cirrhosis is a serious life-threatening complication. In the present study, a novel, reliable and non-invasive score for prediction of rebleeding following endoscopic therapy for esophagogastric variceal bleeding (EGVB) was developed. The present retrospective study recruited cirrhotic patients with EGVB (n=596) who underwent endoscopic therapy. Patients hospitalized from January 2015 to January 2020 were grouped into a training (n=437) cohort to develop the new score and those hospitalized from February 2020 to February 2022 were grouped into a validation (n=159) cohort to validate the score. The international normalized ratio (INR) and albumin-bilirubin (ALBI) grade were used to develop the INR-ALBI (IALBI) score to predict risk of rebleeding. In the training cohort, the prognostic performance of the IALBI score and other ALBI-associated scores (modified ALBI, platelet-ALBI and ALBI-fibrosis-4) at 1, 3 and 12 months was assessed using receiver operating characteristic (ROC) curve and Kaplan-Meier analysis. At each time point, most areas under the ROC curve of IALBI were higher than those of other ALBI-associated scores, particularly for prediction of early rebleeding. At 1 month, the rebleeding rates of patients with IALBI grade 2 and 3 were ~10.0- and 19.5-times higher than those of patients with grade 1, respectively. The negative predictive value (NPV) of IALBI for the training and validation cohort at 1 month was 100.0 and 97.8%, respectively. For viral and non-viral patients in the training cohort, IALBI showed good predictive ability and NPV for early rebleeding. The IALBI grading system successfully assessed rebleeding, particularly early rebleeding, in cirrhotic patients with EGVB following endoscopic therapy IALBI grade 1, predicted low risk of rebleeding and may not require endoscopic treatment again in the short-term.
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Affiliation(s)
- Fenghui Li
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Tao Wang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Jing Liang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Baoxin Qian
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Fei Tang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Yanying Gao
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Jiayu Lv
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
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4
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Intagliata NM, Rahimi RS, Higuera-de-la-Tijera F, Simonetto DA, Farias AQ, Mazo DF, Boike JR, Stine JG, Serper M, Pereira G, Mattos AZ, Marciano S, Davis JPE, Benitez C, Chadha R, Méndez-Sánchez N, deLemos AS, Mohanty A, Dirchwolf M, Fortune BE, Northup PG, Patrie JT, Caldwell SH. Procedural-Related Bleeding in Hospitalized Patients With Liver Disease (PROC-BLeeD): An International, Prospective, Multicenter Observational Study. Gastroenterology 2023; 165:717-732. [PMID: 37271290 DOI: 10.1053/j.gastro.2023.05.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND & AIMS Hospitalized patients with cirrhosis frequently undergo multiple procedures. The risk of procedural-related bleeding remains unclear, and management is not standardized. We conducted an international, prospective, multicenter study of hospitalized patients with cirrhosis undergoing nonsurgical procedures to establish the incidence of procedural-related bleeding and to identify bleeding risk factors. METHODS Hospitalized patients were prospectively enrolled and monitored until surgery, transplantation, death, or 28 days from admission. The study enrolled 1187 patients undergoing 3006 nonsurgical procedures from 20 centers. RESULTS A total of 93 procedural-related bleeding events were identified. Bleeding was reported in 6.9% of patient admissions and in 3.0% of the procedures. Major bleeding was reported in 2.3% of patient admissions and in 0.9% of the procedures. Patients with bleeding were more likely to have nonalcoholic steatohepatitis (43.9% vs 30%) and higher body mass index (BMI; 31.2 vs 29.5). Patients with bleeding had a higher Model for End-Stage Liver Disease score at admission (24.5 vs 18.5). A multivariable analysis controlling for center variation found that high-risk procedures (odds ratio [OR], 4.64; 95% confidence interval [CI], 2.44-8.84), Model for End-Stage Liver Disease score (OR, 2.37; 95% CI, 1.46-3.86), and higher BMI (OR, 1.40; 95% CI, 1.10-1.80) independently predicted bleeding. Preprocedure international normalized ratio, platelet level, and antithrombotic use were not predictive of bleeding. Bleeding prophylaxis was used more routinely in patients with bleeding (19.4% vs 7.4%). Patients with bleeding had a significantly higher 28-day risk of death (hazard ratio, 6.91; 95% CI, 4.22-11.31). CONCLUSIONS Procedural-related bleeding occurs rarely in hospitalized patients with cirrhosis. Patients with elevated BMI and decompensated liver disease who undergo high-risk procedures may be at risk to bleed. Bleeding is not associated with conventional hemostasis tests, preprocedure prophylaxis, or recent antithrombotic therapy.
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Affiliation(s)
| | | | | | | | | | - Daniel F Mazo
- School of Medical Sciences of University of Campinas (UNICAMP), São Paulo, Brazil
| | - Justin R Boike
- Northwestern University Feinburg School of Medicine, Chicago, Illinois
| | - Jonathan G Stine
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Marina Serper
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Gustavo Pereira
- Bonsucesso Federal Hospital (Ministry of Health), Rio de Janeiro, Brazil, and Estácio de Sá School of Medicine-Instituto de Educação Médica, Rio de Janeiro, Brazil
| | - Angelo Z Mattos
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | | | | | - Carlos Benitez
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Nahum Méndez-Sánchez
- Medica Sur Clinic & Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Andrew S deLemos
- Wake Forest University School of Medicine, Atrium Health, Charlotte, North Carolina
| | - Arpan Mohanty
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - Brett E Fortune
- Montefiore Einstein Center for Transplantation, New York, New York
| | | | - James T Patrie
- University of Virginia School of Medicine, Charlottesville, Virginia
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5
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Kataria S, Juneja D, Singh O. Approach to thromboelastography-based transfusion in cirrhosis: An alternative perspective on coagulation disorders. World J Gastroenterol 2023; 29:1460-1474. [PMID: 36998429 PMCID: PMC10044856 DOI: 10.3748/wjg.v29.i9.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023] Open
Abstract
Viscoelastic tests, specifically thromboelastography and rotational thromboelastometry, are increasingly being used in the management of postoperative bleeding in surgical intensive care units (ICUs). However, life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs, especially those with underlying liver dysfunction. Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications. Compared to conventional coagulation tests, a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices, which may aid physicians in making a rapid diagnosis and instituting early interventions. These tests may help predict bleeding and rationalize the use of blood products in these patients.
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Affiliation(s)
- Sahil Kataria
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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6
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The Risk of Endoscopy-Related Bleeding in Patients with Liver Cirrhosis: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010170. [PMID: 36676794 PMCID: PMC9863762 DOI: 10.3390/medicina59010170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
Background and Objectives: The risk of bleeding after endoscopic procedures in patients with liver cirrhosis remains unclear because of secondary blood coagulation disorders. In this study, we used various indices to evaluate the risk of bleeding in patients with cirrhosis. Materials and Methods: Patients with liver cirrhosis aged ≥18 years who underwent endoscopic interventions at Kyung Hee University Hospital at Gangdong between February 2007 and September 2021 were included. Clinical information, including demographic data, laboratory results, the presence of cirrhosis complications, and the degree of fibrosis, was checked and evaluated based on medical records. Results: A total of 101 patients with cirrhosis were analyzed. A total of 16 of the 101 patients (15.8%) experienced bleeding after the endoscopic procedure. One patient (0.99%) presented with spurting, while the others presented with mild oozing. All patients underwent hemostatic procedures using hemoclips. The presence of a varix significantly increased post-endoscopic bleeding (p = 0.03). Patients with FIB > 3.25 showed a statistically significant bleeding tendency (p = 0.00). Conclusions: There was no significant difference in bleeding risk according to the platelet count, prothrombin time, Child−Pugh score, and model for end-stage liver disease (MELD). Considering the degree of liver fibrosis and the invasiveness of the planned procedure, most endoscopic procedures can be performed safely but should be further evaluated in a cohort with a larger sample size.
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7
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Luxenburger H, Schmidt K, Biever P, Supady A, Sekandarzad A, Roehlen N, Reincke M, Neumann-Haefelin C, Schultheiss M, Wengenmayer T, Thimme R, Bettinger D. Survival prediction using the Freiburg index of post-TIPS survival (FIPS) in critically ill patients with acute- on chronic liver failure: A retrospective observational study. Front Med (Lausanne) 2022; 9:1042674. [PMID: 36619640 PMCID: PMC9812953 DOI: 10.3389/fmed.2022.1042674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background and aim Liver cirrhosis in patients treated in the intensive care unit (ICU) is associated with high mortality. Well established scores are useful to allow for assessment of prognosis and support ICU treatment guidance. However, currently used scoring systems often do not reflect the complexity of critically ill patients. Therefore, we tested the newly developed Freiburg index-of post-TIPS survival (FIPS) score in order to assess its potential role for prognostication of cirrhotic patients in the ICU. Methods A total of 310 patients with liver cirrhosis treated in the ICU between 2010 and 2021 were enrolled in this retrospective observational study. Prognostic factors for mortality and 28-day mortality were assessed. Moreover, using c indices the prognostic discrimination of different prognostic scores was analyzed. Results The FIPS score allowed to discriminate patients with high ICU mortality and within 28-days after ICU treatment (ICU mortality: 42.2 vs. 59.9%, p = 0.008 and 28-day mortality: 43.3 vs. 74.1%, p < 0.001). However, the FIPS score in its current composition showed no superior prognostic discrimination compared to other established scores. Multivariable analyses identified the FIPS score (HR 1.25 [1.04-1.49], p = 0.015) and lactate at admission (HR 1.07 [1.04-1.09], p < 0.001) as significant predictors of ICU mortality. Lactate at admission substantially improved patient risk stratification within each FIPS risk groups. Conclusion Similar to other commonly used scores, the FIPS score in its current composition does not allow a sufficiently reliable prognostication of critically ill patients treated in the ICU. However, adding lactate as additional factor to the FIPS score may improve its prognostic ability.
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Affiliation(s)
- Hendrik Luxenburger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,IMM-PACT, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Paul Biever
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Asieb Sekandarzad
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Natascha Roehlen
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,*Correspondence: Dominik Bettinger,
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8
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[Management of acutely decompensated liver cirrhosis in emergency and critical care medicine]. Anaesthesist 2022; 71:403-412. [PMID: 35357555 DOI: 10.1007/s00101-022-01113-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/25/2021] [Accepted: 07/30/2021] [Indexed: 11/01/2022]
Abstract
Acute decompensation in patients with liver cirrhosis is characterized by the development of ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infection and is often accompanied by further extrahepatic organ dysfunction. Since critically ill patients with decompensated cirrhosis have a high mortality risk, rapid identification and treatment of the triggering event of decompensation (e.g., infection, hemorrhage, drugs) as well as specific measures for the treatment of concomitant extrahepatic organ dysfunctions are essential in order to improve the patient's prognosis and to prevent the development of acute-on-chronic liver failure (ACLF).
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9
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Al Sulaiman K, Al Mutairi M, Al Harbi O, Al Duraihim A, Aldosary S, Al Khalil H, Al Shaya A, Al Harbi S, Alotaibi N, Al Aamer K, Vishwakarma R, Al Asiri M, Aljuhani O, Al Katheri A, Al Bekairy AM. Appropriateness of Using Vitamin K for the Correction of INR Elevation Secondary to Hepatic Disease in Critically ill Patients: An Observational Study. Clin Appl Thromb Hemost 2021; 27:10760296211050923. [PMID: 34806430 PMCID: PMC8646191 DOI: 10.1177/10760296211050923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence. This study aims to evaluate the efficacy and safety of vitamin K in the correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients. METHOD A retrospective study of critically ill patients with coagulopathy secondary to liver disease. The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation; other outcomes were considered secondary. Patients were categorized into two groups based on vitamin K administration to correct INR elevation. The propensity score was generated based on disease severity scores and the use of pharmacological DVT prophylaxis. RESULTS A total of 98 patients were included in the study. Forty-seven patients (48%) received vitamin K during the study period. The odds of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P = .42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (P-value: <.0001). However the INR reduction with other subsequent doses of vitamin K was not statistically significant. CONCLUSION The administration of vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower odds of new bleeding events. Further studies are needed to assess the value of vitamin K administration in critically ill patients with liver diseases related coagulopathy.
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Affiliation(s)
- Khalid Al Sulaiman
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Pharmacy, 48149King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Omar Al Harbi
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Sara Aldosary
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Abdulrahman Al Shaya
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Pharmacy, 48149King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Shmeylan Al Harbi
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Pharmacy, 48149King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Nouf Alotaibi
- College of Pharmacy, 48058Umm Al-Qura University, Mecca, Saudi Arabia
| | - Kholoud Al Aamer
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia.,309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- 309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | | | | | - Abdulmalik Al Katheri
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Pharmacy, 48149King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulkareem M Al Bekairy
- 48168King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Pharmacy, 48149King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,309817King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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10
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[Management of acutely decompensated liver cirrhosis in emergency and critical care medicine]. Med Klin Intensivmed Notfmed 2021; 117:73-82. [PMID: 34636958 DOI: 10.1007/s00063-021-00876-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/25/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
Acute decompensation in patients with liver cirrhosis is characterized by the development of ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infection and is often accompanied by further extrahepatic organ dysfunction. Since critically ill patients with decompensated cirrhosis have a high mortality risk, rapid identification and treatment of the triggering event of decompensation (e.g., infection, hemorrhage, drugs) as well as specific measures for the treatment of concomitant extrahepatic organ dysfunctions are essential in order to improve the patient's prognosis and to prevent the development of acute-on-chronic liver failure (ACLF).
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11
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[Clinical presentation of bleeding in critically ill patients in the intensive care unit : Organ systems and clinical implications]. Med Klin Intensivmed Notfmed 2021; 116:482-490. [PMID: 34427697 DOI: 10.1007/s00063-021-00845-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
Bleedings are frequent and clinically important complications in critically ill patients in the intensive care unit, and-depending on location and intensity-are associated with high morbidity and mortality. The clinical impact of different bleeding entities is affected by the location (e.g. intracerebral bleedings), the severity (e.g. fulminant variceal bleeding) and the incidence (e.g. gastrointestinal bleeding) of the respective bleeding type. Therapy varies among bleeding entities, but consists of stabilization of the patient, control of the bleeding, and prevention of complications. This review describes relevant therapeutic aspects of selected bleeding complications in critically ill patients.
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12
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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: 281] [Impact Index Per Article: 93.7] [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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Gaspari R, Teofili L, Aceto P, Valentini CG, Punzo G, Sollazzi L, Agnes S, Avolio AW. Thromboelastography does not reduce transfusion requirements in liver transplantation: A propensity score-matched study. J Clin Anesth 2020; 69:110154. [PMID: 33333373 DOI: 10.1016/j.jclinane.2020.110154] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/05/2020] [Accepted: 11/21/2020] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVE To compare total blood product requirements in liver transplantation (LT) assisted by thromboelastography (TEG) or conventional coagulation tests (CCTs). DESIGN Retrospective observational study. SETTING A tertiary care referral center for LT. PATIENTS Adult patients undergoing LT from deceased donor. INTERVENTION Hemostasis was monitored by TEG or CCTs and corresponding transfusion algorithms were adopted. MEASUREMENTS Number and types of blood products (red blood cells, RBC; fresh-frozen plasma, FFP; platelets, PLT) transfused from the beginning of surgery until the admission to the intensive care unit. METHODS We compared data retrospectively collected in 226 LTs, grouped according to the type of hemostasis monitoring (90 with TEG and 136 with CCTs, respectively). Confounding variables affecting transfusion needs (recipient age, sex, previous hepatocellular carcinoma surgery, Model for End Stage Liver Disease - MELD, baseline hemoglobin, fibrinogen, creatinine, veno-venous by pass, and trans-jugular intrahepatic portosystemic shunt) were managed by propensity score match (PSM). MAIN RESULTS The preliminary analysis showed that patients in the TEG group received fewer total blood products (RBC + FFP + PLT; p = 0.001, FFP (p = 0.001), and RBC (p = 0.001). After PSM, 89 CCT patients were selected and matched to the 90 TEG patients. CCT and TEG matched patients received similar amount of total blood products. In a subgroup of 39 patients in the top MELD quartile (MELD ≥25), the TEG use resulted in lower consumption of FFP units and total blood products. Nevertheless, due to the low number of patients, any meaningful conclusion could be achieved in this subgroup. CONCLUSIONS In our experience, TEG-guided transfusion in LT does not reduce the intraoperative blood product consumption. Further studies are warranted to assess an advantage for TEG in either the entire LT population or the high-MELD subgroup of patients.
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Affiliation(s)
- Rita Gaspari
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Paola Aceto
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Caterina G Valentini
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giovanni Punzo
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Salvatore Agnes
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alfonso W Avolio
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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14
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Chua MMJ, Das AS, Losman JA, Patel NJ, Izzy S. Spontaneous hemorrhage after external ventricular drain placement in the setting of low factor VII secondary to liver cirrhosis. Surg Neurol Int 2020; 11:403. [PMID: 33365166 PMCID: PMC7749959 DOI: 10.25259/sni_446_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/06/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Alterations in normal coagulation and hemostasis are critical issues that require special attention in the neurosurgical patient. These disorders pose unique challenges in the management of these patients who often have concurrent acute ischemic and hemorrhagic injuries. Although neurosurgical intervention in such cases may be unavoidable and potentially life-saving, these patients should be closely observed after instrumentation. CASE DESCRIPTION A 57-year-old male with liver cirrhosis secondary to amyloid light-chain amyloidosis was admitted to the intensive care unit for the management of delayed hydrocephalus. An external ventricular drain (EVD) was placed for the treatment and monitoring of hydrocephalus. Five days after EVD placement, a head computed tomography scan revealed a tract hemorrhage. However, on repeated imaging, the size of the hemorrhage continued to increase despite aggressive blood pressure control and several doses of phytonadione. Extensive coagulopathy workup was remarkable for low factor VII levels. In that setting, recombinant activated factor VII was administered to normalize factor VII levels, and the tract hemorrhage stabilized. CONCLUSION To the best of our knowledge, this is the first case of spontaneous hemorrhage after EVD placement in the setting of liver cirrhosis-associated factor VII deficiency. Our case highlights the importance of identifying coagulation disorders in neurosurgical patients at high risk for coagulopathy and closely monitoring them postoperatively.
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Affiliation(s)
- Melissa Ming Jie Chua
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Alvin S. Das
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Julie Aurore Losman
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Nirav J. Patel
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, United States
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15
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Stotts MJ, Lisman T, Intagliata NM. The Spectrum of Disease Severity in Cirrhosis and Its Implications for Hemostasis. Semin Thromb Hemost 2020; 46:716-723. [PMID: 32820482 DOI: 10.1055/s-0040-1715449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bleeding and thrombosis are both common complications that patients with advanced liver disease experience. While hemostatic pathways remain largely intact with cirrhosis, this balance can quickly shift in the direction of bleeding or clotting in an unpredictable manner. A growing body of literature is attempting to shed light on difficult scenarios that clinicians often face, ranging from predicting and mitigating bleeding risk in those who need invasive procedures to determining the best strategies to manage both bleeding and thrombotic complications when they occur. Studies examining hemostasis in those with advanced liver disease, however, often include heterogeneous cohorts with varied methodology. While these studies often select a cohort of all types and degrees of cirrhosis, emerging evidence suggests significant differences in underlying systemic inflammation and hemostatic abnormalities among specific phenotypes of liver disease, ranging from compensated cirrhosis to decompensated cirrhosis and acute-on-chronic liver failure. It is paramount that future studies account for these differing disease severities if we hope to address the many critical knowledge gaps in this field.
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Affiliation(s)
- Matthew J Stotts
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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16
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Neuberger J, Patel J, Caldwell H, Davies S, Hebditch V, Hollywood C, Hubscher S, Karkhanis S, Lester W, Roslund N, West R, Wyatt JI, Heydtmann M. Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology. Gut 2020; 69:1382-1403. [PMID: 32467090 PMCID: PMC7398479 DOI: 10.1136/gutjnl-2020-321299] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.
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Affiliation(s)
- James Neuberger
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jai Patel
- Department of Vascular Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Helen Caldwell
- Liver Unit, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Susan Davies
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Coral Hollywood
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Stefan Hubscher
- Department of Pathology, University of Birmingham, Birmingham, UK
| | - Salil Karkhanis
- Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Judith I Wyatt
- Department of Pathology, St James University Hospital, Leeds, UK
| | - Mathis Heydtmann
- Department of Gastroenterology, Royal Alexandra Hospital, Glasgow, UK
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Gurumurthy G, Gaddam A, Patel V, Patel RS. Coagulopathy and Hospital Outcomes in Patients With Spontaneous Bacterial Peritonitis: A Call for Action to Improve Care of Inpatients. Cureus 2020; 12:e8926. [PMID: 32760626 PMCID: PMC7392352 DOI: 10.7759/cureus.8926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objectives To assess the risk of in-hospital mortality in spontaneous bacterial peritonitis (SBP) with coagulopathy, and to understand the impact of comorbid coagulopathy on length of stay (LOS) and total charges for SBP inpatients. Methods We included adult patients (age, 18-50 years) with a principal diagnosis of SBP using the Nationwide Inpatient Sample (NIS, 2012 to 2014). These patients were further subgrouped by comorbid coagulopathy. The independent sample t-test was used to measure the mean difference in LOS and total charges between subgroups. The logistic regression model was used to measure the odds ratio (OR) of association of coagulopathy and in-hospital mortality after adjusting for demographic confounders and other comorbid risk factors. Results SBP with comorbid coagulopathy was prevalent in males (68.7%) and white (58.1%). When compared with the non-coagulopathy cohort, males had 1.6 times (95% CI 1.46-1.84), and hispanics had 1.4 times (95% CI 1.19-1.58) high odds for coagulopathy. In-hospital mortality was statistically significant in SBP inpatients with coagulopathy (6.5% vs. 2.8% in non-coagulopathy), and with two times higher odds of association (95% CI 1.47-2.51) compared with non-coagulopathy cohort. SBP inpatients with comorbid coagulopathy had a statistically significantly higher LOS by 1.1 days and higher total charges by $14,123 per hospitalization compared with the non-coagulopathy cohort. Conclusions Coagulopathy is a significant risk factor that increases the risk of in-hospital mortality in SBP inpatients by 92%. Comorbid coagulopathy is also associated with extended LOS and higher hospitalization costs, thereby increasing the healthcare burden. Clinicians need to effectively manage coagulopathy in SBP patients to improve patient outcomes and reduce the healthcare burden with better health-related quality of life.
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Affiliation(s)
| | - Anusha Gaddam
- Internal Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, IND
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Katsounas A, Canbay A. Intensive Care Therapy for Patients with Advanced Liver Diseases. Visc Med 2018; 34:283-289. [PMID: 30345286 DOI: 10.1159/000492088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Decompensated cirrhosis is characterized by high hospitalization rates and costs, frequent readmissions, and poor short-term survival. Patients admitted to the hospital with acute variceal bleeding and/or hepatic encephalopathy and/or renal dysfunction are at serious risk for developing infection and/or sepsis; in turn, this renders them highly susceptible to the development of multi-system organ failure. The lack of standardized intensive care unit management protocols in patients with cirrhosis along with only few data reports from longitudinal clinical trials makes it difficult for hepatologists and critical care specialists to provide uniform evidence for clinical practice that could safely consolidate favorable outcomes such as lower hospitalization rates and/or mortality. Based on a rigorous online search of the scientific literature as well as a longtime clinical experience of the authors in the field of hepatology and critical care medicine, this work represents a focused effort to elucidate the specific bio-morbidity of advanced liver diseases in relation to the aforementioned challenges in clinical management. Further meta-analyses and/or systematic reviews are needed to enable clinicians to develop more effective strategies to bridge patients with decompensated liver disease to recompensation or liver transplantation.
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Affiliation(s)
- Antonios Katsounas
- Department for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Ali Canbay
- Department for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
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