Management of coagulopathy among patients with cirrhosis undergoing upper endoscopy and paracentesis: Persistent gaps and areas of consensus in a multispecialty Delphi

Abstract

Background and Aims Patients with cirrhosis have abnormal coagulation indices such as a high international normalized ratio (INR) and low platelet count, but these do not correlate well with peri-procedure bleeding risk. We sought to develop consensus among the multiple stakeholders in cirrhosis care to inform process measures that can help improve the quality of the peri-procedure management of coagulopathy in cirrhosis. Approach and Results We identified candidate process measures for peri-procedure coagulopathy management in multiple contexts relating to the performance of paracentesis and upper endoscopy. An 11-member panel with content expertise was convened. It included nominees from professional societies for interventional radiology, transfusion medicine, and anesthesia as well as representatives from hematology, emergency medicine, transplant surgery, and community practice. Each measure was evaluated for agreement using a modified Delphi approach (3 rounds of rating) to define the final set of measures. Out of 286 possible measures, 33 measures made the final set. INR testing was not required for diagnostic or therapeutic paracentesis as well as diagnostic endoscopy. Plasma transfusion should be avoided for all paracenteses and diagnostic endoscopy. No consensus was achieved for these items in therapeutic intent or emergent endoscopy. The risks of prophylactic platelet transfusions exceed their benefits for outpatient diagnostic paracentesis and when platelet counts >20,000/mm3. It is uncertain whether risks outweigh benefits below 20,000/mm3 in other contexts. No consensus was achieved on whether it was permissible to continue or stop systemic anticoagulation. Continuous aspirin was permissible for each procedure. Clopidogrel was permissible for diagnostic and therapeutic paracentesis and diagnostic endoscopy. Conclusions We found many areas of consensus that may serve as a foundation for a common set of practice metrics for the peri-procedure management of coagulopathy in cirrhosis.

Gerinnungsstörungen bei Leberzirrhose – Diagnostik und Management

“…▶ Abb. 1 Algorithmus zur Risikostratifikation und Gerinnungsoptimierung vor elektiven Prozeduren bei Zirrhose (Daten aus [57,58]). Fußnoten: 1) ▶ Tab.…”