Clinics in liver disease
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Coagulopathy is an essential component of the acute liver failure (ALF) syndrome and reflects the central role of liver function in hemostasis. ALF is a syndrome characterized by the development of hepatic encephalopathy and coagulopathy within 24 weeks of the onset of acute liver disease. ⋯ If severe, it can be associated with bleeding and is commonly a major obstacle to the performance of invasive procedures in patients with ALF. This review focuses on the epidemiology, pathophysiology, presentation, evaluation, and management of coagulopathy in ALF.
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Clinics in liver disease · Feb 2009
The role of anti-fibrinolytics, rFVIIa and other pro-coagulants: prophylactic versus rescue?
Patients who have liver disease experience an increased risk for bleeding and resulting complications. Diseases affecting the liver can cause a deficiency of pro-coagulant factors or induce a state of increased clot breakdown. ⋯ This article discusses the use of activated factor VIIa and anti-fibrinolytic agents to treat coagulopathy in the setting of liver disease and the potential advantages and disadvantages of these alternatives, and the limitations of the current literature. This article also compares the limitations, risks, and potential benefits of prophylactic therapy to prevent bleeding before invasive procedures with rescue therapy for spontaneous and postprocedure bleeding, and describes the relative advantages and disadvantages of these two approaches.
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Intraoperative blood loss and transfusion of blood products are negatively associated with postoperative outcome after liver surgery. Blood loss can be minimized by surgical methods, including vascular clamping techniques, the use of dissection devices, and the use of topical hemostatic agents. ⋯ Maintaining a low central venous pressure has been shown to be effective in reducing blood loss during partial liver resections, and volume contraction rather than prophylactic transfusion blood products seems justified in patients undergoing major liver surgery. Although antifibrinolytic drugs have proved to be effective in reducing blood loss during liver transplantation, systemic hemostatic drugs are of limited value in reducing blood loss in patients undergoing partial liver resections.
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The complex coagulation defect secondary to chronic liver disease is considered responsible for the bleeding problems that often are associated with the disease. Accordingly, clinicians order laboratory tests to assess the risk of bleeding and rely on these results to make decisions about the management of the associated coagulation disturbances. Recent data, however, indicate that the abnormality of coagulation in stable cirrhosis is more a myth than a reality and may help explain why the prolonged global coagulation tests are poor predictors of bleeding in this setting. Alternative tests more closely mimicking what occurs in vivo should be developed and investigated in appropriate clinical trials to determine their value in the management of bleeding in cirrhosis.
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The coagulation "cascade" model accurately represents the mechanisms of the prothrombin time and activated partial thromboplastin time tests. However, these tests and the "cascade" model do not accurately reflect the risk of hemorrhage or thrombosis in vivo. ⋯ However, the ability of the coagulation system to tolerate or recover from an insult is markedly impaired in liver disease. This allows the coagulation system to be more easily tipped into a state favoring either hemorrhage or thrombosis.