Background and rationale {6a}
The peri-procedural assessment of haemostasis in patients with cirrhosis remains challenging for clinicians.
Historically, cirrhosis had been labelled as a bleeding disorder due to the abnormalities in conventional coagulation tests seen, namely prolonged prothrombin time (PT)/international normalised ratio (INR), and thrombocytopenia. On this basis, traditionally, attempts have been made to correct these parameters with blood component prophylaxis prior to invasive procedures in this patient population [
1].
More recently, the concept of “rebalanced haemostasis” in cirrhosis was developed and is now well-established [
2]. In addition to the reduction in procoagulants, and thrombocytopenia typically associated with advanced liver disease, there is also a reduction in anticoagulants and an increase in von Willebrand factor and factor VIII [
3], leading to a new haemostatic balance. This balance, however, is delicate and can be easily disturbed, predisposing the patient with cirrhosis to both bleeding and thrombotic complications [
4].
While patients with cirrhosis do have an increased risk of bleeding complications, aside from portal hypertensive-related events, they experience disproportionately fewer bleeding complications than would be expected by their INR/PT and platelet count values [
5]. For most patients, the increased bleeding risk relates to portal hypertension, endothelial dysfunction, bacterial infection, and renal failure rather than defective haemostasis (at least that which is assessed by INR/platelet count) [
6‐
8]. There is now robust evidence that INR/PT do not predict procedure-related bleeding in patients with cirrhosis [
9]. The potential impact of thrombocytopenia on procedural bleeding risk remains unclear, with some studies suggesting an increased risk of bleeding in patients with platelet counts less than 50 × 10
9/L [
10], while others do not show a relationship [
11‐
13]. Despite frequent abnormalities in conventional coagulation tests, in most patients with cirrhosis thrombin generation is preserved [
14].
Up-to-date international clinical practice guidelines acknowledge the limitations of standard haemostatic tests, particularly prothrombin time/INR, in predicting procedure-related bleeding, and as a consequence, no longer recommend routine pre-procedural blood component prophylaxis based on these parameters [
15‐
17]. Despite this, clinical practice has been slow to change, and patients with cirrhosis are still frequently given blood component products, based on their INR and platelet count abnormalities, in an attempt to reduce peri-procedural bleeding [
18]. Although the overall risk of bleeding for patients with cirrhosis undergoing procedures remains low, particularly for low-risk procedures [
19‐
22], there is a subset of patients who do bleed, which is likely to explain the clinician tendency to “correct” standard coagulation tests abnormalities with pre-procedural blood product administration that has continued regardless of guidelines recommending against it. This is despite an acknowledgement that there are significant risks associated with blood component therapy, particularly large-volume products such as FFP, including fluid overload, pulmonary oedema, allergic reactions, and elevation in portal pressure [
23,
24].
It is imperative that an improved method of assessing procedure-related bleeding risk in patients with cirrhosis is developed and validated, so that blood products can be efficiently and effectively allocated in this patient population.
In recent years, ‘global’ coagulation tests, such as ThromboElastoGraphy(TEG) and Rotational Thromboelastometry (ROTEM) have been developed. Whereas platelet counts, INR and APTT measure only individual components of the haemostatic system, ROTEM and TEG measure the viscoelastic properties of whole blood to provide a measure of overall haemostasis, from clot formation to clot retraction and fibrinolysis [
25]. These point-of-care tests provide quick results and have been used to assess coagulation and guide blood product transfusion in a number of surgical and trauma settings, including liver transplantation [
26]. In these settings, these tests predict bleeding and thrombotic risks more accurately than conventional coagulation tests, are associated with a reduction in intra-operative blood loss, decreased rates of blood product usage, and improved mortality [
27].
Recently, there has been increasing interest in the use of these viscoelastic tests in liver disease outside of the transplant setting. Two randomised controlled trials have found that using TEG to guide prophylactic blood component transfusion in patients with cirrhosis undergoing invasive procedures resulted in decreased blood product use without affecting bleeding outcomes [
28,
29]. Similarly, a randomised controlled trial found that using ROTEM to guide pre-procedural blood product transfusion in the cirrhotic
children having invasive procedures led to decreased FFP and platelet use, with no significant difference in procedure-related bleeding [
30].
We designed this study to assess the utility of a ROTEM-based algorithm to guide prophylactic blood component delivery in adult patients with cirrhosis undergoing invasive procedures. We hypothesise that ROTEM-based decision-making will lead to a reduction in pre-procedural blood component usage, particularly FFP, compared with standard of care. We anticipate that there will be no difference in bleeding complications between the two groups.
By attempting to establish the role of ROTEM in assessing coagulation status in patients with chronic liver disease, we hope to improve the identification of those patients with cirrhosis who are and are not at increased bleeding risk, and in turn, improve the identification of those patients who are most likely to benefit from blood component transfusion.