Predicting postprocedure bleeding in liver disease

Abstract

Prophylactic transfusions of fresh frozen plasma and platelets are sometimes given to patients with mild elevations in prothrombin time (PT) and partial thromboplastin time (PTF) and mild thrombocytopenia before percutaneous liver biopsy. To determine whether PTs and PTFs 1.1–1.5 times midrange normal levels and platelet counts 50–99 × 10 9 /L are associated with increased bleeding complications, hospital records of all patients who underwent percutaneous liver biopsy during 56 consecutive months (n = 291) were reviewed. Complete information was available for 177 inpatient procedures (155 standard, 22 fine needle). Overall, the frequency of bleeding complications in patients with platelet counts ± 50 × 10 9 /L was 3.4% (6 of 175), with no significant difference between patients with mild hemostatic abnormalities and patients with normal parameters. These data suggest that prophylactic transfusions may not be necessary. One factor was highly associated with bleeding complications: a patient diagnosis of malignancy, 14% (7 of 50) compared with 0.8% (1 of 127) among other patients ( P < 0.001). These patients should be monitored closely after biopsy. To determine whether untreated mild coagulopathy in patients with no evidence of clinical bleeding is associated with an increased risk of hemorrhage after paracentesis or thoracentesis, retrospective examination was conducted of 608 consecutive procedures for which prothrombin time (PT), partial thromboplastin time (PTT), platelet (Plt) counts, and preprocedure and postprocedure hemoglobin concentrations were available. There was no increased bleeding in patients with mild to moderate coagulopathy (defined as PT or PTT up to twice the midpoint normal range or plt count of 50 to 99 × 10 3 per ΜL [50–99 × 10 9 L]). However, patients with markedly elevated serum creatinine levels (6.0 to 14.0 mg/dL [530–1240 Μmol/L]) had a significantly greater average hemoglobin loss (-0.82 ± 1.3 g/dL [-8 ± 13 g/L], n = 11) than patients with normal serum creatinine levels (-0.12 ± 088 g/dL [-1 ± 9 g/L], n = 450) (p = 0.011). Overall, the frequency of bleeding complications requiring red cell transfusions was very low: 0.2 percent of events. The most common diagnosis for patients who had paracentesis was alcoholic liver disease (72%); for those having thoracentesis, it was infection (37%). It can be concluded that, for these patients, prophylactic plasma or platelet transfusions are not necessary. Patients with markedly elevated serum creatinine deserve close postprocedure observation.