Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials

Abstract

Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03–0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30–0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.

“Periprocedural management of abnormal coagulation parameters and thrombocytopenia in patients with cirrhosis: Guidance from the SSC of the ISTH”: Comment from Hartmann et al.

“…1 • A significant reduction in utilization of several allogeneic blood products, specifically fresh frozen plasma and platelets. 7,8 • A trend toward reduction in transfusion related adverse events, while other clinical outcomes do not appear to be affected by the more restrictive VET-guided transfusion approach. 7 Recently added prospective research strengthens the available evidence.…”

“…7,8 • A trend toward reduction in transfusion related adverse events, while other clinical outcomes do not appear to be affected by the more restrictive VET-guided transfusion approach. 7 Recently added prospective research strengthens the available evidence. Based on the consistent reported findings we propose that rather than focus on VET purely for the prediction or reduction of bleeding (at least in the overall population of patients with cirrhosis), more research should be directed toward rational blood product utilization guided by VET.…”

“…Our research identified five relevant RCTs using thromboelastography. 7 Independently, another team published a similar meta-analysis, including two additional thromboelastometrybased RCTs. 8 These large pooled RCT data that include more than 300 patients consistently report that with the use of VET-guided transfusion decision making, there is:…”

“…• No significant reduction in bleeding events in the overall population with cirrhosis. 7,8 The exception may be in those with decompensated cirrhosis, as suggested by the results of the small prospective study in hospitalized patients 9 that is referenced in the guidance document. 1 • A significant reduction in utilization of several allogeneic blood products, specifically fresh frozen plasma and platelets.…”

Thromboelastogram and coagulation function index: relevance for female breast cancer

“…The clinical significance is not limited to thrombotic disease ( 47 ), thrombocytopenia, coagulation factor deficiency diseases, and hyperfibrinolytic disease. A series of parameters are derived and presented following TEG ( 48 ). The R value indicates the time required for the initiation of clotting and the formation of initial fibrin clots.…”