But the INR is 3.2! Markers of Coagulation Status in Cirrhotics

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Rout G, Shalimar, Gunjan D, et al. Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding. J Clin Gastroenterol 2019;54(3):255–62.

This study was a single-center, prospective, open-label, randomized controlled trial of patients with cirrhosis and acute variceal bleeding. Patients were randomized to blood product resuscitation guided by either TEG parameters or conventional coagulation tests (INR, platelet count, and fibrinogen). A total of 60 adult patients with cirrhosis and coagulopathy via conventional coagulation tests were enrolled.  In the conventional transfusion group, patients with INR > 1.8 received weight-based FFP transfusion. For platelet counts less than 50,000 they received 3 units platelets. In the TEG groups, patients were transfused weight-based FFP for R time > 15 minutes and platelets for maximum amplitude < 30 mm.

The primary outcome was reduction in blood product utilization and secondary outcome was early rebleeding (at day 5) or late rebleeding (day 42). The secondary outcome was mortality at 6 weeks. Across the board, transfusion volumes were significantly less in the TEG group. Rebleeding was similar at day 5 and there was no difference in mortality at 6 weeks. There was a significant difference in late rebleeding, with lower rates in the TEG-guided transfusion group.

Overall, the findings of this trial support the AASLD’s current guidelines and offer more evidence that the INR should not be used as a marker of bleeding risk or transfusion threshold. Some limitations include relatively limited size with only 30 patients in each group. However, this remains the only randomized-controlled trial to compare TEG-guided to conventional transfusion strategies in variceal hemorrhage.

Written by Annie Grisoli, PGY-3, University of Cincinnati Department of Emergency Medicine

Editing, Posting by Jeffery Hill, MD MEd, Associate Professor University of Cincinnati Department of Emergency Medicine

Cite As: Grisoli, A., Hill, J. But the INR is 3.2! Markers of Coagulation Status in Cirrhotics. www.tamingthesru.com. www.tamingthesru.com/blog/journal-club/cirrhosis-teg. 7/17/2024