assessing and correcting for bleeding risk prior to invasive procedures (bsh 2008, ISTH 2021)
assessment of bleeding risk prior to surgery (bsh 2008)
Key message
Patients with a negative bleeding history do not require laboratory screening
Defining high vs low bleeding risk procedures (ISTH 2021)
Estimated risk of a particular procedure causing bleeding
Ease of controlling any bleeding that occurs
Potential consequences of any bleeding that occurs
(N.B. Major bleeding risk >1.5% = High bleeding risk procedure)
Consequences of unselected coag testing prior to surgery:
Delays surgery
Anxiety for patients
False reassurance to surgeon
Expensive and uses up lab time
All this, and it is a poor predictor of bleeding risk
Notes
‘Normal Range’ = 2 SD above and below the mean in disease-free subjects.
—> Therefore, 2.5% of disease-free subjects will have an abnormal result
Result may be normal in patients at risk of bleeding
E.g. Some APTT reagents only sensitive to FVIII <30 iu/dL —> will miss mild haem A / VWD
PT/APTT may be normal in patients taking direct oral anticoagulants
Or result maybe abnormal in a healthy patient
E.g. FXII deficiency, Lupus Anticoagulant
Preventing procedural bleeding in liver cirrhosis (ISTH 2021)
Intro
Prophylactic correction of abnormal clotting tests / platelet counts prior to procedures in patients with cirrhosis is common, but this practice is not supported by the available evidence.
‘Rebalanced haemostasis’ refers to the observations that despite the correlation between the degree of derangement of clotting studies with the disease severity of the cirrhosis, this does not automatically lead to an increased bleeding risk. E.g.
Low coagulation factors affect PT/APTT, but liver-derived anticoagulant factors will also be low
Low platelet counts but elevated VWF levels
Low fibrinolytic and antifibrinolytic factors
This is supported by results of global tests of haemostasis which have shown hypercoaguable states in chronic and acutely decompensated cirrhosis.
Patient Factors affecting bleeding risk
Anticoagulants, antiplatelets
Infection
Anaemia
Renal failure
Portal hypertension
?Bleeding history - careful when taking, consider whether bleeding pre-dates the cirrhosis.
Procedural Factors affecting bleeding risk
Estimated risk of a particular procedure causing bleeding
Ease of controlling any bleeding that occurs
Potential consequences of any bleeding that occurs
Guideline contains a table listing procedures and their bleeding risk
Management
PT/INR/APTT/Platelet count should not be used routinely to predict bleeding risk pre-procedure, therefore:
Prophylactic correction of abnormal clotting tests count not advised
Prophylactic platelet count correction for patients with a plt count >30 only advised for very high risk surgeries (Platelet count <30 = consider alternative causes to liver disease)
Review modifiable risk factors for bleeding - drugs, infection, renal impairment
?Vitamin K - single dose of 10mg may correct prolonged PT/APTT. Repeated doses not indicated
?Tranexamic acid - no studies in this setting. Consider as an intervention if bleeding occurs
?TPO agonists - Avatrombopag and Lusutrombopag approved for chronic liver disease prior to invasive procedures. Maximum rise in platelet count occurs approx. day 12. Meta-analysis has confirmed efficacy on raising platelet count, but less clear whether this actually leads to reduced procedure-related bleeding.
See also
Prospective observational study. >1000 hospitalised liver disease pts undergoing non-surgical procedures
Major bleeding occurred in 0.9% of high risk procedures
Risk of bleeding associated with high risk procedures, MELD score and BMI >40
Pre-procedure INR and platelet count were not predictive of bleeding (FGN not assessed)
Joint BSH and British Society for Interventional Radiology Guideline 2023
Categorises IR procedures by risk and recommends pre-procedure measures accordingly
British Society of Gastroenterology Guidelines 2020
Strongly recommend against the use of FFP to correct an INR <2.0 prior to liver biopsy, supported by cochrane review 2019
No evidence that it reduces bleeding events
Some evidence that if bleeding does occur, it may be aggravated by increased portal pressures following plasma transfusions.
FFP & Cryo page