Thromboelastography for assessing risk of bleeding in patients with cirrhosis - Moving closer

Abstract Background and aims Conventional coagulation tests (CCTs) in patients with cirrhosis only assess procoagulant factors and are poor predictors of bleeding risk. In spite of this knowledge they are routinely used prior to invasive procedures and attempts are made to correct these abnormalities before invasive procedures. These practices are not supported by the evidence and are harmful to the patients. Methods This prospective study included 150 patients of cirrhosis undergoing invasive procedures. CCTs [bleeding time (BT), clotting time(CT), International normalized Ratio (INR), Activated partial thromboplastin time(aPTT) and platelet count], thromboplastin generation time (TGT) and thromboelastography (TEG) were done in all patients and they were observed for post procedural bleeding. None of the patients had received prophylactic transfusion before the procedure. Results BT, CT and TGT were normal in all 150 patients. One of 150 patients developed clinically significant post procedural bleeding. No statistically significant association was seen between INR, aPTT, platelet count and Child class with bleeding. TEG values (R time and MA value) were normal in 61% and 75% patients respectively in spite of abnormal CCTs in most of them. Comparison of abnormal TEG values (R time and MA value) with INR and Platelet count respectively in patients with no bleeding showed statistically significant lower percentage of abnormal values of R time and MA value compared to INR and platelet count. Conclusion Abnormal CCTs in patients of cirrhosis do not predict bleeding risk.TEG may be useful in patients undergoing invasive procedures to assess bleeding risk and prevents erroneous prophylactic transfusions.