Management of Bleeding and Thrombosis in Critically Ill Patients with Liver Disease

Abstract

Bleeding frequently complicates end-stage chronic liver disease, and may follow procedures which are required for effective care of patients with liver failure. Thrombosis is increasingly recognized as common, important, and potentially preventable. Standard laboratory tests may not be useful in predicting bleeding or thrombotic risk or guiding therapy, and functional testing serves a more useful role. A state of rebalanced hemostasis exists in many patients, with hypocoagulability present only in a minority. Approaches to management are poorly supported by high-quality evidence; in this review, a practical pragmatic approach to care and minimization of procedure-related risk is discussed. General measures include the correction of systemic factors that may affect coagulation status, prevention and treatment of infection, and individualized coagulation support therapies for specific clinical situations and procedures.

Development and validation of a dynamic outcome prediction model for paracetamol-induced acute liver failure: a cohort study

“…Coagulopathy was not supported unless active haemorrhage was present. 15 Norepinephrine was the primary vasopressor used and dobutamine the primary ionotropic agent with adjunctive use of intravenous lowdose hydrocortisone and vasopressin. Renal replacement therapy used continuous veno-venous haemofi ltration.…”

In vitro efficacy of pro‐ and anticoagulant strategies in compensated and acutely ill patients with cirrhosis

“…It is unknown whether acutely ill patients with cirrhosis are at risk for development of venous thrombosis similar to the increased risk in well compensated patients . Nevertheless, prophylactic or therapeutic antithrombotic strategies may be required in acutely ill patients with cirrhosis, in the context of venous thrombosis, portal vein thrombosis, and thrombosis of extracorporeal assist devices …”

“…22 Nevertheless, prophylactic or therapeutic antithrombotic strategies may be required in acutely ill patients with cirrhosis, in the context of venous thrombosis, portal vein thrombosis, and thrombosis of extracorporeal assist devices. 15,23 We have recently studied the haemostatic status of patients with acutely decompensated or acute-on-chronic liver failure and found a remarkably preserved haemostatic system. 24 The relatively wellpreserved haemostatic balance therefore suggests that a defensive prohaemostatic and a proactive antihaemostatic approach may be warranted in these patients.…”

Hemostatic Dysfunction in Liver Diseases

“…23 Intagliata and Northup then discuss opportunities and pitfalls for prevention and treatment of thrombotic disease in patients with liver diseases using anticoagulant therapy. 24 A pragmatic approach to prevention and treatment of bleeding and thrombosis in critically ill patients with liver disease is then provided by Roberts and Bernal, 25 and Mallett subsequently outlines how viscoelastic tests of coagulation help in management decisions on bleeding and thrombosis in patients with liver disease and during liver transplantation. 26 Finally, Massicotte et al present data from their institution which uses state-of-the-art approaches to prevention of blood loss during liver transplantation.…”