Thromboelastography and blood product usage in cirrhosis with severe coagulopathy
Authors: Antoni Sabate, Annabel Blasi
Journal: Hepatology (2017)

Potential conflict of interest: Nothing to report. TO THE EDITOR: We read with great interest the article by De Pietri et al.1 evaluating the use of thromboelastography (TEG) as a guide for fresh frozen plasma (FFP) and platelets before invasive procedures in patients with cirrhosis and would like to address some questions about the study trial. The selected thresholds for FFP and platelet administration in TEG parameters (reaction time [40 minutes] and maximum amplitude [30 mm]) are very conservative in comparison with selected thresholds for international normalized ratio (1.8) and platelet count (50,000 × 109/L). This fact limits both the clinical value of TEG in guiding replacement of blood product and moreover the sample size calculated in the study protocol. In terms of efficacy, red blood cells were administered in a similar percentage in both groups (16%). Prophylactic administration of blood products is not justifiable in patients who undergo low‐ to moderate‐risk procedures; on the contrary, it might be justifiable in patients undergoing high‐risk procedures, and this question was not answered by De Pietri's study. De Pietri et al. included very few surgical procedures (hepatic resection, n = 5; other abdominal surgery, n = 4; thoracotomy, n = 1), and these patients probably had almost normal coagulation status before the procedure (though we could not find data to support this assessment in the published article). Patients who have cirrhosis are usually excluded for abdominal surgery because of their high rates of morbidity and mortality, and bleeding is one of the relevant complications in these patients during and after surgery. Therefore, more knowledge is needed regarding prediction and prevention of bleeding due to hemostatic and coagulation correction in patients undergoing high‐risk procedures. Unfortunately, this question remains unresolved. On the other hand, experiences in liver transplantation (LT) cannot be directly extrapolated to non–liver‐related surgery. Higher Model for End‐Stage Liver Disease scores have better outcomes in LT in comparison with major non–liver‐related surgery. In LT, the interaction between thrombin and fibrinogen affects both the thickness and the fibrinolytic resistance of fibrin fibers. The speed of these reactions depends on the plasma fibrinogen concentration. In gross hemodilution or active bleeding, the correlation between maximum amplitude with fibrinogen and platelets is reduced in comparison with the baseline (i.e., preprocedure) determination. It would have been beneficial if TEG for functional fibrinogen had been performed in the study. In our recent study of the value of prophylactic fibrinogen administration in LT, we found that although preemptive administration of fibrinogen concentrate increased plasma levels of fibrinogen to normal values and increased maximum clot firmness, these gains did not reduce the need for red blood cell transfusions in LT.2 However, we confirmed the vast loss of plasma fibrinogen during LT and the need for intraoperative fibrinogen replacement. These data can be used to define a strategy in high‐risk surgical procedures.