Patient, 55 years old, diaphragm hernia operation.
Cirrhosis is detected intraoperatively (no clinical manifestations). This patient doesn't show history of viral infection of the liver or the use of toxic substances.
The only laboratory parameter which was without normal range: prothrombin 28% with INR 2.36, in postoperative period.
The patient shows no signs of active bleeding, the response to administration of vitamin K (10mg) was minor (TP 40% after 6 hours).
What it is your opinion about indication to transfuse FFP in this case to correct prothrombin complex?
It would be sufficient reserves liver cells that respond to the vitamin K?
Thank you in advance for your help.
My suggestion would be monitor for bleeding post op and only transfuse plasma if any bleeding where to occur. 3 doses of SQ vit K 10 mg each dose will be enough to ensure there is no nutritional deficiency.
what about liver enzymes, bilirubin and serum albumen? There might be acute on chronic injury to the liver cells due to drugs,anesthesia or effect of hypoxia
To Dr. Mostafa Ragheb.
Liver enzymes was elevated ten times the normal range. Bilirubin and albumin level in normal range. Also, you have reason, this patient developed a respiratory hypoxia, due to an important atelectasis, especially in the left side (region were abdominal content was in thoracic department). This problem was resolved with non invasive ventilation 1h each 4h.
Only transfuse if bleeding is present! But be careful with inactived fresh frozen plasma with blue metilen: fibrigen is not functional.
Of course, I will administer with k vitamin ev (be careful with alergic risk)
In case of bleeding, if the patients hasn´t got thrombotic or thrombophilia, and there is not volume depletion, prothrombin complex concentrates could be an option, but four components ones!.
In case of hepatic failure we must forget hypofibrinogenemia and hyperfibrionolysis.
A ROTEM study must be perform.
I agree with José García-Erce. The patient should be treated if clinical bleeding occurs. In presence of coagulopathy reconstitution of coagulation by transfusion of fresh frozen plasma is highly ineffective. I would also recomment functional tests (e.g. ROTEM or TEG) to enable a goal directed therapy by administation of the missing factors (most likely 4 factor PCC in your case).
And:
- Transfusion Associated Cardiovascular Overload (TACO)
- Anemia dilution!
- and hypocalcemia, acydosis and hypothermia!!
I agree with previous collegues! You have also to remember that the cirrhotic patient could have a hemostatic balance shifted to a hypercoagulable state (reduction of protein C and ATIII), undetectable by PT and aPTT. I also suggest Thrombin Generation Test to understand where the balance hangs.
In my view there is no need to consider correction of INR=2.36 if there is no clinical or laboratory sign of bleeding. FFP would be the way to correct if needed.
Response to vitamin K would be expected if the patient had hypovitaminosis - coagulopathy of parenchymal liver disease typically cannot be corrected by adding vitamin K and giving it therefore may be futile. Lack of response would be certainly not a good gauge of residual liver functional capacity
In moderate or severe bleeding with coagulation altered tests that could be corrected with FFP transfusion.
It is not indicated in case of thrombocytopathy or thrombocitopenia, in case of hypo or disfibrinogenemia, in case of heparin treatment, in case of antivitamin K treatment
vitamin K is not the targeted therapy for prolonged PT secondary to liver cirrhosis plasma transfusion should be indicated if the patient has bleeding tendency
No transfusion of fresh frozen plasma requred because absence of active haemorragy
FFP should be used only for patietns with active/recent bleeding or those having plan for invasive procedure.
But, are we using the same kind of "plasma"?
There are some differences between: "recovery plasma", "fresh frozen plasma" (FFP) and "securized" FFP! Quaranteened FFP is better than "inactived" plasma!
But, amotsalen is better than "metilen blue" inactivated FFP?
Wich is your experience or expertise?
Thanks
Methilen blue treated plasma has a signficant decreased level of fibrinogen and lower level of FVII. It works worse and you will need higher volume (much donors and more risks)
FFP of course is not indicated so long as no active bleeding and no plan for further intervention. Vit. K in cirrhotic has minor role unless there is some sort of cholestasis and the Vit. is given parenteral to correct the deficit .
Only in those with active bleeding and in those requiring an invasive procedure at high risk of bleeding
There is no incication for FFP if there is no haemorage. Moreover, the effect of this procedure is limited in the time and, then, only justified by active events or surgical operations. I think that the main problem in this patient is related to assess a possible cause of his cirrhosis (autoimmune, methabolic?) and the presence of portal hypertension. Prothrombin time may be a sign of reduced parenchimal function of the liver: other indicators may be helpful (albumin, cholesterol, cholinesterase, ammonium) in order to obtain a general trait of liver function.
We must not forget that the cirrhotic patient also presents evidence of thrombophilia
Of course!
There is a decrease of several coagulation factors, but also an umpaired anticoagulation proteins realease and cleavage!, and a fbrinolysis disbalance, with a trend to hyperfibrinolisis and disfibrinogenemia!
Unnecessary plasma transfusion (with citrate as anticoagulant) could modify this fragil balance
FFP should only be given if the cirrhotic patient bleeds along with other appropriate treament but it can cauce or exacerbate DIC, ARDS which such patients are predisposed to. It should never be given for correction of deranged prothrombin time only
Because the high prevalence of cirrhosis in our community, we used to face many patients with cirrhosis related complications. Of these, ascites, bleeding tendencies, variceal bleeding, pleural effusion, scrotal edema. Although, there are no solid indications for the use of fresh frozen plasma in these patients, our expeience emphasized its effectivness in all the aforementioned complications. Regarding ascites, plamsa infusion together with diuretic therapy yeild very good results and the same also applied for bleeedig tendecy. plasma infusion not only supply clotting factors but also albumin. In the low income communities like ours plama infusion is relatively less expensive to the albumin infusion. In variceal bleeding we use blood tranfusion +/- plasma. pleuarl effusion, from my expeience is the least complication from the above mentioned that may benefit from plasma. My personal expeience in patients with scrotal edema emphasizes its effectivness when combined with high doses of diuretics. Cirrhotic patients who are facing surgery should also recieve plasma together with other blood elements, particullary in the post-operative follow up, it definetly improve healing and the frequence of ascites after the operation
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