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

PROC-Bleed 2023

  • 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.

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