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Assessment and management of coagulopathy in critically-ill patients with liver failure

Saner, Fuat H.a; Bezinover, Dmitrib

Current Opinion in Critical Care: April 2019 - Volume 25 - Issue 2 - p 179–186
doi: 10.1097/MCC.0000000000000591
GASTROINTESTINAL SYSTEM: Edited by Constantine J. Karvellas
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Purpose of review This review provides insight into our current understanding of the pathophysiology and treatment of coagulopathy associated with liver failure, and bleeding risk assessment.

Recent findings Patients with end-stage liver disease (ESLD) have a rebalanced coagulation profile and are at risk for both excessive clotting and bleeding. Hypercoagulability is associated with profound endothelial dysfunction and an increased concentration of liver-independent coagulation factors. Because of this rebalanced coagulation profile, standard laboratory tests have been demonstrated to be ineffective in either predicting and/or guiding the management of coagulopathy. Viscoelastic testing, however, is able to provide a dynamic assessment of clot formation in whole blood and has been demonstrated to be invaluable in both monitoring and management of coagulation problems associated with liver failure. More recently, there is increasing interest in thrombin generation tests to monitor coagulation in patients with ESLD.

Multiple institutional protocols for prophylaxis and treatment of ESLD-related thromboses have been developed. High-quality studies evaluating these approaches are lacking.

Summary Patients with ESLD are at risk for excessive bleeding and clotting. Treatment of any significant coagulopathy should not be based solely on standard laboratory tests. Thrombosis prophylaxis has to be considered in susceptible populations.

aDepartment of General, Visceral and Transplant Surgery, Medical Center, Universitätsklinikum Essen, University Duisburg-Essen, Essen, Germany

bDepartment of Anesthesia and Perioperative Medicine, Penn State College of Medicine, Penn State University, Hershey, Pennsylvania, USA

Correspondence to Fuat H. Saner, Department of General, Visceral and Transplant Surgery, Medical Center, Universitätsklinikum Essen, University Duisburg-Essen, Hufelandstr. 55, 45 147 Essen, Germany. Tel: +49 201 723 84008; fax: +49 201 723 1145; e-mail: fuat.saner@uni-due.de

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