Department of Gastroenterology, Alfred Health.
Central Clinical School, Monash University, Melbourne, Victoria, Australia.
Eur J Gastroenterol Hepatol. 2022 Feb 1;34(2):192-199. doi: 10.1097/MEG.0000000000001948.
Standard coagulation parameters are used to guide prophylactic blood product transfusion prior to invasive procedures in cirrhotic patients despite limited high-quality evidence.
We aimed to describe coagulation parameters and prophylactic blood product use in cirrhotic patients having invasive procedures, and the influence of both on periprocedural bleeding.
We conducted a cohort study of cirrhotic patients undergoing invasive procedures at a referral hospital. Procedures were classified into low or moderate-high bleeding risk. Prophylactic blood component was defined as fresh frozen plasma, cryoprecipitate or platelet transfusion prior to procedures. Univariate and multivariate logistic regression was performed to identify factors associated with procedure-related bleeding.
We identified 566 procedures in 233 cirrhotic patients. Prophylactic blood product was given before 16% of high-risk and 11% of low-risk procedures (P = 0.18). Eight (8.3%) high-risk procedures were complicated by postprocedural bleeding, six of which occurred in patients without significant coagulopathy. The bleeding rate for low-risk procedures was 0.4%. For patients with international normalized ratio >1.5, platelet count <50 x 109/L, or both, the rate of bleeding was comparable between those given and not given prophylactic blood products (3.1 vs. 1.9%; P = 0.63). After adjusting for age, sex, platelet count, international normalized ratio, acute kidney injury, sepsis and model of end-stage liver disease, the only factor significantly predicting procedure-related bleeding was the procedural bleeding risk category (P < 0.01).
Procedure-related bleeding in cirrhotic patients cannot be accurately predicted by INR or platelet count, nor prevented by blood component prophylaxis using these parameters. Procedure-related bleeding is best predicted by the bleeding risk status of procedures.
尽管缺乏高质量的证据，但在进行侵入性操作之前，标准凝血参数被用于指导肝硬化患者预防性输血。
我们旨在描述接受侵入性操作的肝硬化患者的凝血参数和预防性输血情况，并研究其对围手术期出血的影响。
我们对一家转诊医院进行了一项肝硬化患者接受侵入性操作的队列研究。将操作分为低危或中高危出血风险。预防性输血是指在操作前输注新鲜冰冻血浆、冷沉淀或血小板。采用单因素和多因素逻辑回归分析确定与操作相关出血相关的因素。
我们共确定了 233 例肝硬化患者的 566 次操作。16%的高危操作和 11%的低危操作给予了预防性血液制品（P=0.18）。8 次（8.3%）高危操作出现术后出血，其中 6 例发生在无明显凝血障碍的患者中。低危操作的出血率为 0.4%。对于国际标准化比值（INR）>1.5、血小板计数<50×109/L 或两者兼有的患者，给予和未给予预防性血液制品的出血率相似（3.1% vs. 1.9%；P=0.63）。在校正年龄、性别、血小板计数、INR、急性肾损伤、脓毒症和终末期肝病模型后，唯一显著预测操作相关出血的因素是操作出血风险类别（P<0.01）。
INR 或血小板计数不能准确预测肝硬化患者的操作相关出血，也不能通过这些参数的血液成分预防性治疗来预防。操作相关出血最好通过操作的出血风险状态来预测。
