Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand

Abstract

Background and Aim: To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). Methods: Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. Results: We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62 s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P < 0.0001). Median initial lowest platelet count was 83 (IQR 41-122) × 10 9 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. Conclusion: In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

“…170 In patients with ALF, elevated INR does not correlate with the risk of bleeding complications even though it is a marker of poor prognosis in many predictive indices, whereas thrombocytopenia is associated with bleeding complications as well as with poor outcome. [171][172][173] In a retrospective cohort of patients with ALF, bleeding occurred in around one-fifth of the patients and thrombotic events in 10% of the patients, hypofibrinogenaemia was common at ICU admission in patients with ALF and was more severe in patients with bleeding complications. 173 As bleeding complications are not frequent in patients with ALF, routine prophylactic correction of SLTs or of platelet levels is not necessary.…”

“…[171][172][173] In a retrospective cohort of patients with ALF, bleeding occurred in around one-fifth of the patients and thrombotic events in 10% of the patients, hypofibrinogenaemia was common at ICU admission in patients with ALF and was more severe in patients with bleeding complications. 173 As bleeding complications are not frequent in patients with ALF, routine prophylactic correction of SLTs or of platelet levels is not necessary. 172,174 However, when correction of abnormal haemostasis is necessary, platelets appear to be the most important, followed by fibrinogen correction and by PT prolongation correction.…”

Effect of Perioperative Coagulation Monitoring by Sonoclot on Short-Term Thrombosis in Pediatric Liver Transplantation

“…Clotting factor production is signi cantly reduced in the perioperative period anhepatic phase. The release of toxic substances that accumulate from the lower part of the body and perfuse the donor liver after ischemia-reperfusion causes a large blow to the neohepatic stage liver [10,18] . Liver coagulation function drops again.…”

Diagnosis of human immunodeficiency virus associated disseminated intravascular coagulation

“…Albumin is a negative acute phase reactant and is often reduced in severe infection. It may also, however, reflect liver synthetic dysfunction [25]. The majority of coagulation factors are synthesised in the liver and the prothrombin time, in particular, is a sensitive indicator of liver disease.…”