Disorders of Hepatic and Mesenteric Circulation

1. We do not recommend fresh frozen plasma FFP to improve thrombin generation in patients with cirrhosis at conventional doses (10 mL/kg). If sufficient volume is given (1–2 L) to lower a significantly prolonged INR, volume expansion increases portal pressure and may trigger variceal hemorrhage. Thus in most situations, infusion of plasma prophylactically to decrease bleeding risk is futile and potentially risky. (Conditional (weak)  “We suggest”, Low)

2. We do not recommend prophylactic platelet transfusions before common procedures such as routine variceal banding or paracentesis outside of significant renal dysfunction (serum creatinine >2.5 mg/dL) or sepsis. Existing data indicate a somewhat tenuous relationship between bleeding risk and platelet count. In vitro studies demonstrate adequate thrombin production with platelet levels ≥50,000/mL. Infusion of a single adult platelet dose does not improve thrombin generation. Higher platelet levels may bemore appropriate for high-risk procedures such as removal of large polyps and major surgery but will probably require higher doses of platelet infusions. If the procedure is elective, the use of thrombopoietin (TPO) agonists may be more appropriate. (Conditional (weak)  “We suggest”, Very low)

3. We do not recommend antifibrinolytic agents such as epsilon aminocaproic acid and tranexamic acid to reduce bleeding in the absence of hyperfibrinolysis. These agents are not generally considered to induce a hypercoagulable state but require caution if pathological clot such as portal vein thrombosis (PVT) is already present. (Conditional (weak)  “We suggest”, Very low)