Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

Abstract

Background Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. Objectives We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. Patients/Methods Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. Interventions: Restrictive protocol, thromboelastometry‐guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (ie, fresh frozen plasma, platelets, or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion‐related adverse events. Results A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 ± 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry‐guided arm, and 14/19 (73.7%) in the coagulogram‐guided arm received blood transfusion (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01‐0.45; P = .002 for restrictive versus coagulogram‐guided arm; OR, 0.09; 95% CI, 0.01‐0.56; P = .006 for restrictive versus thromboelastometry‐guided arm; and OR, 0.77; 95% CI, 0.14‐4.15; P = .931 for thromboelastometry‐guided versus coagulogram‐guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion‐related adverse events was found. Conclusions The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.

Coagulation Homeostasis in Liver Disease

“…12 Increasingly, however, whole blood viscoelastic testing (thromboelastography (TEG), rotational thromboelastometry [ROTEM], and sonorheometry) is being successfully used to support more restrictive approaches to prophylaxis without obvious detriment. 13 Other key considerations that may impair hemostasis include infection and renal failure as noted earlier. Our understanding of changes in fibrinogen physiology in cirrhosis (dysfibrinogen) is emerging as to whether these changes enhance or diminish clot stability.…”

Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease

“…Patients with restrictive transfusion protocol received less transfusions than the thromboelastometry-guided and coagulogramguided groups, without any increase in adverse events. 22 While this study was likely underpowered to detect differences between the restrictive and thromboelastometryguided groups (only 19 patients per group), the study highlights a need for further diagnostic advances, particularly because viscoelastic tests lack sensitivity to VWF and protein C, which may lead to underestimation of hemostatic capacity. 23 Thus, TEG or other viscoelastic tests may be useful to help guide use of both platelet transfusions and TPO receptor agonists, but additional hemostatic tests are needed to fully capture bleeding versus thrombotic risks.…”

“…In addition, higher rates of thromboembolic events were noted in the eltrombopag-treated groups (3 vs. 1%). 22 Eltrombopag was also studied in patients with CLD undergoing procedures. 38 The ELEVATE trial was a randomized, placebo-controlled trial with planned enrollment of 500 patients that was terminated early due to increased incidence of thrombotic events among eltrombopag-treated patients.…”

Viscoelastic Tests as Point-of-Care Tests in the Assessment and Management of Bleeding and Thrombosis in Liver Disease

“…The only randomized trial using ROTEM in this setting compared three prophylactic transfusion protocols (ROTEMguided protocol vs. restrictive protocol vs. standard practice) in 57 acutely unwell patients with cirrhosis and coagulopathy undergoing central venous catheterization (►Table 5). 43 The use of a restrictive blood component strategy significantly reduced blood component use and associated costs, without an increase in bleeding complications compared with both ROTEM-and CCT-guided transfusion protocols. Interestingly, there was no reduction in the proportion of patients requiring prophylactic blood products in the ROTEM-guided group compared with the SOC group (odds ratio: 0.77; 95% confidence interval: 0.14-4.15; p ¼ 0.931).…”