• Leonardo Lima Rocha, Camila Menezes Souza Pessoa, Neto Ary Serpa AS Adult Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil., do Prado Rogerio Ruscitto RR Adult Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil., Eliezer Silva, Marcio Dias de Almeida, Thiago Domingos Correa, and POCKET Trial Investigators.
• Adult Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil. lrocha23@gmail.com.
• Trials. 2017 Feb 27; 18 (1): 85.

BackgroundLiver failure patients have traditionally been empirically transfused prior to invasive procedures. Blood transfusion is associated with immunologic and nonimmunologic reactions, increased risk of adverse outcomes and high costs. Scientific evidence supporting empirical transfusion is lacking, and the best approach for blood transfusion prior to invasive procedures in cirrhotic patients has not been established so far. The aim of this study is to compare three transfusion strategies (routine coagulation test-guided - ordinary or restrictive, or thromboelastometry-guided) prior to central venous catheterization in critically ill patients with cirrhosis.Methods/DesignDesign and setting: a double-blinded, parallel-group, single-center, randomized controlled clinical trial in a tertiary private hospital in São Paulo, Brazil.Inclusion Criteriaadults (aged 18 years or older) admitted to the intensive care unit with cirrhosis and an indication for central venous line insertion. Patients will be randomly assigned to three groups for blood transfusion strategy prior to central venous catheterization: standard coagulation tests-based, thromboelastometry-based, or restrictive. The primary efficacy endpoint will be the proportion of patients transfused with any blood product prior to central venous catheterization. The primary safety endpoint will be the incidence of major bleeding. Secondary endpoints will be the proportion of transfusion of fresh frozen plasma, platelets and cryoprecipitate; infused volume of blood products; hemoglobin and hematocrit before and after the procedure; intensive care unit and hospital length of stay; 28-day and hospital mortality; incidence of minor bleeding; transfusion-related adverse reactions; and cost analysis.DiscussionThis study will evaluate three strategies to guide blood transfusion prior to central venous line placement in severely ill patients with cirrhosis. We hypothesized that thromboelastometry-based and/or restrictive protocols are safe and would significantly reduce transfusion of blood products in this population, leading to a reduction in costs and transfusion-related adverse reactions. In this manner, this trial will add evidence in favor of reducing empirical transfusion in severely ill patients with coagulopathy.Trial RegistrationClinicalTrials.gov, identifier: NCT02311985 . Retrospectively registered on 3 December 2014.

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