Description
An indicator of the clinical efficacy of vitamin-K antagonist therapy is the international normalized ratio (INR). Nonetheless, it is frequently employed in the acute context to evaluate the level of coagulopathy in individuals suffering from acute liver failure or hepatic cirrhosis. This frequently affects therapeutic choices regarding invasive operations or the necessity of potentially hazardous and needless blood product transfusions. This might not be an evidence-based or best-practice method of patient care. Using a number of scholarly search engines, the author conducted a study of the literature regarding the usefulness of INR in cirrhosis patients. The literature contradicts the widely held belief that a cirrhotic patient's elevated INR during invasive operations translates into a higher risk of hemorrhagic events.
Summary Listen
- Dr. Rohit discussed the misunderstood coagulopathy in liver diseases, challenging common myths and outlining a rational approach to managing bleeding risk. He emphasized that conventional coagulation tests, like INR and platelet counts, only represent a small part of the complex hemostatic balance in cirrhosis. In reality, cirrhotic patients have a rebalanced hemostasis with both pro-coagulant and anti-coagulant changes.
- Dr. Rohit debunked the routine practice of correcting INR with FFP transfusions before procedures. Studies show that FFP transfusions do not significantly improve thrombin generation and can even be detrimental by increasing portal pressure and mortality, especially in cases of variceal bleeding. Vitamin K administration is also often ineffective since vitamin K absorption is usually preserved in cirrhosis unless cholestatic liver disease is present.
- The discussion shifted to platelet transfusions and thrombopoietin agonists. While low platelet counts may be associated with increased bleeding risk, transfusing platelets or using agonists might not always translate to clinical benefits. These interventions might primarily serve to satisfy arbitrary thresholds rather than demonstrably improving patient outcomes.
- Dr. Rohit presented tranexamic acid (TXA) use in patients with cirrhosis. TXA did not improve mortality or bleeding risk in this patient group. Deep vein thrombosis and seizures were more frequent in patients receiving TXA, advocating for restrictive TXA use limited to cases with clinically evident hyperfibrinolysis.
- Global coagulation tests like thromboelastography (TEG) and rotational thromboelastometry (ROTEM) offer a more comprehensive assessment of coagulation, measuring viscoelastic properties of whole blood from clot formation to lysis. These tests can help decrease unnecessary blood product transfusions before invasive procedures, leading to better outcomes by preventing complications associated with over-transfusion.
- Dr. Rohit concluded by emphasizing that cirrhosis is a state of rebalanced hemostasis, and routine correction of INR is generally unwarranted. Clinicians should focus on treating the underlying liver disease, assessing procedural risks based on a global assessment of coagulation, and individualizing the use of blood component transfusions based on viscoelastic testing results, rather than relying solely on conventional coagulation parameters.
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