Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Hepatology. 2024 Aug 1;80(2):488-499. doi: 10.1097/HEP.0000000000000856. Epub 2024 Apr 1.
Patients with cirrhosis have abnormal coagulation indices such as a high international normalized ratio and low platelet count, but these do not correlate well with periprocedural bleeding risk. We sought to develop a consensus among the multiple stakeholders in cirrhosis care to inform process measures that can help improve the quality of the periprocedural management of coagulopathy in cirrhosis. We identified candidate process measures for periprocedural coagulopathy management in multiple contexts relating to the performance of paracentesis and upper endoscopy. An 11-member panel with content expertise was convened. It included nominees from professional societies for interventional radiology, transfusion medicine, and anesthesia as well as representatives from hematology, emergency medicine, transplant surgery, and community practice. Each measure was evaluated for agreement using a modified Delphi approach (3 rounds of rating) to define the final set of measures. Out of 286 possible measures, 33 measures made the final set. International normalized ratio testing was not required for diagnostic or therapeutic paracentesis as well as diagnostic endoscopy. Plasma transfusion should be avoided for all paracenteses and diagnostic endoscopy. No consensus was achieved for these items in therapeutic intent or emergent endoscopy. The risks of prophylactic platelet transfusions exceed their benefits for outpatient diagnostic paracentesis and diagnostic endosopies. For the other procedures examined, the risks outweigh benefits when platelet count is >20,000/mm 3 . It is uncertain whether risks outweigh benefits below 20,000/mm 3 in other contexts. No consensus was achieved on whether it was permissible to continue or stop systemic anticoagulation. Continuous aspirin was permissible for each procedure. Clopidogrel was permissible for diagnostic and therapeutic paracentesis and diagnostic endoscopy. We found many areas of consensus that may serve as a foundation for a common set of practice metrics for the periprocedural management of coagulopathy in cirrhosis.
肝硬化患者的凝血指数异常，例如国际标准化比值升高和血小板计数降低，但这些与围手术期出血风险并不相关。我们试图在肝硬化治疗的多个利益相关者中达成共识，以确定有助于改善肝硬化凝血功能障碍围手术期管理质量的流程措施。我们确定了多个与经皮穿刺和上内窥镜相关的围手术期凝血功能障碍管理的候选流程措施。一个具有内容专业知识的 11 人小组被召集在一起。其中包括介入放射学、输血医学和麻醉专业协会的提名人选，以及血液学、急诊医学、移植外科和社区实践的代表。使用改良 Delphi 方法（3 轮评分）评估每项措施的一致性，以确定最终的措施集。在 286 个可能的措施中，有 33 个措施进入了最终的措施集。诊断性或治疗性经皮穿刺术以及诊断性内窥镜检查不需要进行国际标准化比值检测。所有经皮穿刺术和诊断性内窥镜检查均应避免输注血浆。在治疗性或紧急内窥镜检查中，对于这些项目没有达成共识。预防性血小板输注的风险超过其对门诊诊断性经皮穿刺术和诊断性内窥镜检查的益处。对于其他检查的程序，当血小板计数>20,000/mm 3 时，风险超过收益。在其他情况下，血小板计数<20,000/mm 3 时，风险是否超过收益尚不确定。对于是否可以继续或停止全身抗凝治疗，也没有达成共识。对于每个程序，持续使用阿司匹林是可以的。氯吡格雷可用于诊断性和治疗性经皮穿刺术和诊断性内窥镜检查。我们发现了许多共识领域，这些领域可能成为肝硬化围手术期凝血功能障碍管理的通用实践指标的基础。
