Table 6.

General recommendations for blood component transfusion prior to an invasive procedure in patients with ALF

Hemostatic parameter	Transfusion/Infusion	Threshold to replete
INR	Plasma	Unknown
Platelet count	Platelets	< 60 × 109/L
Fibrinogen	Cryoprecipitate	< 100 mg/dL
Hemoglobin	RBCs	< 7 g/dL

Abbreviations: ALF, acute liver failure; INR, international normalized ratio; RBC, red blood cell.

Note: Although the cause of much consternation to clinicians caring for patients with ALF, the implication of an elevated INR in estimating bleeding risk is unclear.⁶⁸ Before an invasive procedure, we suggest considering the transfusion of 1–2 units of plasma shortly before the procedure, then proceeding with the procedure without repeating the INR.

Platelets should be transfused if peripheral counts are < 60 × 10⁹, with consideration of a higher threshold for transfusion in the setting of renal failure. Fibrinogen should be repleted with cryoprecipitate or fibrinogen concentrate if blood concentration is < 100 mg/dL. Red blood cells (RBCs) should be transfused if the hemoglobin is < 7 g/dL. These recommendations are primarily made on the basis of studies in patients with cirrhosis rather than ALF.⁷⁶ In a patient with ALF who is actively bleeding, all blood components should be repleted, including plasma.