Department of Emergency Medicine, Ipswich Hospital, Ipswich, Queensland, Australia.
Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
Emerg Med Australas. 2023 Feb;35(1):89-96. doi: 10.1111/1742-6723.14058. Epub 2022 Aug 22.
Management of coagulopathy in chronic liver disease (CLD) poses a challenge for critical care physicians. Prothrombinex®-VF is a low-volume product with rapid onset of action. Evidence for its efficacy and safety in CLD is limited and cases of acute intravascular coagulation and fibrinolysis (AICF) and/or disseminated intravascular coagulation (DIC) have been reported. Our objective was to evaluate the role of Prothrombinex®-VF in reversal of coagulopathy and the incidence AICF/DIC, thromboembolic events and mortality.
This was a retrospective, multi-centre study of Prothrombinex®-VF use in CLD across 11 hospitals over a 2-year period, excluding those on therapeutic anticoagulation. Patients were subclassified into acute on chronic liver failure (ACLF), acute decompensation (ADC) and compensated cirrhosis. Reversal of coagulopathy was defined as international normalised ratio (INR) <1.5× upper limit normal (ULN), prothrombin time <1.5× ULN, activated partial thromboplastin time <1.5× ULN and fibrinogen >1 g/L. Markers of AICF/DIC were recorded.
Thirty CLD patients were included, and the median model for end-stage liver disease score was 23.5. Acute bleeding was the most common indication for Prothrombinex®-VF (60%). All had baseline coagulopathy and the majority did not achieve reversal. Key indicators of AICF/DIC were mainly observed in those with ACLF; bleeding from mucosa or lines (53%), worsening hypofibrinogenaemia (60%), worsening thrombocytopaenia (60%). The ADC and compensated cirrhosis groups were relatively unaffected. Incidence of venous thromboembolism was 6%. Overall mortality was 43% and 70% in ACLF.
Prothrombinex®-VF did not lead to meaningful reversal of coagulopathy and should be used with caution in CLD. Patients with ACLF were more likely to develop AICF/DIC following Prothrombinex®-VF, although the association is uncertain. Further studies are needed to evaluate the safety and efficacy of Prothrombinex®-VF use in CLD.
慢性肝脏疾病（CLD）患者凝血异常的管理对重症监护医生来说是一个挑战。Prothrombinex®-VF 是一种低容量产品，起效迅速。目前有关其在 CLD 中的疗效和安全性的证据有限，并且已经有报道称其可引起急性血管内凝血和纤维蛋白溶解（AICF）和/或弥散性血管内凝血（DIC）。我们的目的是评估 Prothrombinex®-VF 在逆转凝血异常以及 AICF/DIC、血栓栓塞事件和死亡率中的作用。
这是一项为期 2 年、涉及 11 家医院的 Prothrombinex®-VF 在 CLD 中的应用的回顾性多中心研究，不包括接受治疗性抗凝治疗的患者。患者被细分为急性失代偿期（ADC）、慢加急性肝衰竭（ACLF）和代偿性肝硬化。凝血异常的逆转定义为国际标准化比值（INR）<1.5×正常值上限（ULN）、凝血酶原时间（PT）<1.5×ULN、活化部分凝血活酶时间（APTT）<1.5×ULN 和纤维蛋白原>1 g/L。记录 AICF/DIC 的标志物。
共纳入 30 例 CLD 患者，中位终末期肝病模型评分（MELD）为 23.5。急性出血是使用 Prothrombinex®-VF 的最常见指征（60%）。所有患者均存在基线凝血异常，大多数患者未达到逆转。AICF/DIC 的关键指标主要见于 ACLF 患者；黏膜或管路出血（53%）、纤维蛋白原恶化（60%）、血小板计数恶化（60%）。ADC 和代偿性肝硬化组相对未受影响。静脉血栓栓塞症的发生率为 6%。总体死亡率为 43%，ACLF 患者的死亡率为 70%。
Prothrombinex®-VF 并未导致凝血异常的显著逆转，在 CLD 中应谨慎使用。使用 Prothrombinex®-VF 后，ACLF 患者更有可能发生 AICF/DIC，尽管其相关性不确定。需要进一步的研究来评估 Prothrombinex®-VF 在 CLD 中的安全性和疗效。
