TABLE 2.

Bleeding prophylaxis and treatment in cirrhosis

Prophylaxis
High risk	Target	Value	Agent(s)	Comment
High-risk procedures: Major surgery* Intra-cranial or spinal procedures	Platelet count	>50 000*	Platelet transfusion Oral thrombopoietin agonists	TPO is superior to platelet transfusion as it does not increase portal pressure and results in more prolonged elevations in platelet count. However, TPO requires 10 d to take effect and does carry increased risk of PVT, although newer agents including avatrombopag and lusutrombopag seem to mitigate this risk.45,59 *liver transplant surgery is the exception and can be safety carried out with platelet counts <50 00045
	Fibrinogen	>120 mg/dL	Cryoprecipitate Fresh-frozen plasma	No controlled trials exist, but in the acute high-risk presurgical setting, correction is warranted to create additional substrate for clot formation. For this purpose, cryoprecipitate is preferred over FFP as it is delivered in smaller volume and less likely to exacerbate portal HTN.6,45,59
			Tranexamic acid (TXA)	Prophylactic use prior to liver transplantation has demonstrated successful reductions in blood loss and transfusion requirements, although not in mortality.41–43
	INR	N/A	Correction not recommended.	There is no specific INR cutoff above which bleeding can be reliably predicted.102
			FFP	Not recommended for use. Requires high transfusion volume, significant effects on portal pressure limit use.59
			Prothrombin complex	The use is limited due to monitoring and dosage dependency on INR, although low volume of administration minimizes risk of the use. The literature on the use in cirrhosis is limited.59
			Vitamin K	Requires >12 h to exert an effect. Paucity of data available to guide patient selection, and dosing. May be useful in patients with malnutrition or prolonged antibiotic therapy.59
	TEG	N/A		Although holistic evaluations of coagulation can meaningfully guide transfusion strategies on a case-by-case basis, validated target levels do not yet exist.59
Low risk	Target	Value	Agent(s)	Comment
Paracentesis Thoracentesis	Platelet count	N/A		Routine evaluation and correction are not recommended in this setting.
Routine endoscopy	INR	N/A
Treatment	Agent	Comment
	PRBC transfusion	Transfusion threshold of Hb 7 improves outcomes in cirrhotic patients with upper GI bleed.82
	Recombinant factor VIIa	Randomized controlled trials have not demonstrated benefit in terms of cessation or reduction of bleeding, or short-term mortality, although may have long-term benefit in the treatment of massive variceal hemmorhage.6,103,104
	Desmopressin	Enhances platelet function in uremia. Recommended for bleeding in patients with concomitant renal failure. Lacks evidence for use in isolated cirrhosis, in which it has not been demonstrated to reduce bleeding.2,45,59
	Tranexamic acid	Not believed to generate a hypercoagulable state, although may exacerbate existing thrombi. Typically utilized for postprocedural bleeding.45,59
	Aminocaproic acid

^*Liver transplant surgery is the exception and can be safely carried out with platelet counts <50,000.