Thromboelastography-guided Blood Product Transfusion in Patients with Chronic Liver Disease Undergoing Invasive Liver-related Procedures: A Randomized Controlled Trial

Sudheer Kumar Vuyyuru, Shalimar, Gyan Ranjan Rout, Ashish Chauhan, Shivanand Gamanagatti, Baibaswata Nayak, Saurabh Kedia: Department of Gastroenterology, All India Institute of Medical Sciences,New Delhi

Background: We aimed to assess the use of thromboelastography (TEG) directed blood product transfusion in cirrhotic patients undergoing invasive liver-related procedures compared to standard of care (SOC) correction of coagulopathy.

Methods: In this open label, randomized control trial, cirrhotic patients with coagulopathy, undergoing invasive liver-related procedures, were randomized - to either TEG - guided blood product transfusion or SOC from November 2017 till April 2018.

The primary outcome was difference in the amount of fresh frozen plasma (FFP) and platelet units transfused between the two groups. Secondary outcome measures were procedure related bleeding complications within five days.

Results: Of the 30 patients, 15 were randomized to the TEG group and 15 to the SOC. Procedures performed were percutaneous liver biopsy (N =21), sphincterotomy with stone removal (n =1), transjugular intrahepatic portosystemic shunt (TIPS) ( n =1), pigtail drainage of empyema ( n =1), percutaneous acetic acid injection (PAI) for hepatocellular carcinoma (HCC) (n=2) and transarterial chemoembolization (TACE) (n=2), pigtail drainage of intraperitoneal collections (n=1) and hepatic vein angioplasty (n=1).

There were no differences in baseline demographic profile and types of invasive liver -related procedures between the two groups. All 15 subjects in the SOC group received blood product transfusions, vs. 5 in the TEG group (100% vs. 33.3%; p<0.001). In the SOC group, 9 (60%) received platelet transfusions, 6 (40%) received FFP and no patient received both FFP and platelets.

In the TEG group, 2 (13.3%) received FFP (p = 0.215 vs. SOC), 3 (20%) received platelets (p =0.128 vs. SOC) and no patient received both FFP and platelet. None of the patients in either group developed procedure related bleeding complications immediately post procedure or till 5 days of follow up.

Conclusion: TEG - guided blood product transfusion strategy was associated with reduced blood product transfusion without increased risk of bleeding in cirrhotic patients undergoing invasive liver-related procedures.