Reappraisal of the conventional hemostasis tests as predictors of perioperative bleeding in the era of rebalanced hemostasis in cirrhosis.

Abstract

New global laboratory procedures mimicking the in vivo hemostasis process, led to the changing paradigm of cirrhosis from the prototype of hemorrhagic diseases to a condition in which hemostasis is normal but fragile, thus justifying the hemorrhagic/thrombotic tendencies that affect these patients. The new paradigm was instrumental to change the management of cirrhosis. For examples, international guidelines warn against the entrenched practice of testing patients with conventional hemostasis tests and infusing those with abnormalities with fresh-frozen plasma, coagulation factor concentrates, or platelets, prior to surgery/invasive procedures. These recommendations are, however, largely disattended. The practice of testing patients with the prothrombin time (PT) or viscoelastometry and using arbitrary cut-offs to make decision on perioperative prophylaxis is still common and probably driven by medico-legal issues. There is no doubt that PT and congeners tests are unable to predict bleeding in cirrhosis. However, it cannot be excluded that some tests may be useful in severely decompensated patients. Large prospective collaborative studies are warranted. Enrolled patients should be randomized to receive perioperative prophylaxis based on laboratory testing (e.g., viscoelastometry, thrombomodulin-modified thrombin generation, etc.) or to usual care. However, for these trials to be useful, a third group of patients who do not receive prophylaxis should be included. In conclusion, until results from these studies are available, physicians attending cirrhosis should refrain from using laboratory tests with arbitrary cut-offs to make decision on perioperative prophylaxis. Decision should be made by consideration of the clinical history in individual patients and risk of hemorrhage of specific procedures.