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lunes, 7 de diciembre de 2015

Coagulopatía en el cirrótico sangrante

PulmCrit - December 7, 2015 by Josh Farkas
Hemorrhage is a common cause of death in cirrhosis, especially variceal bleeding. These patients often have complex coagulopathies. Furthermore, some coagulation abnormalities may precede variceal re-bleeding (Chau 1998). Thus, immediate and definitive coagulation management is important. Unfortunately, the traditional approach is misguided and potentially dangerous...
  • Most cirrhotics are in a state of rebalanced hemostasis, due to similar reductions in pro- and anti-coagulant proteins. This often yields a normal overall clotting tendency.
  • INR measures the level of clotting factors only, not the overall balance of coagulation. To determine the balance of enzymatic coagulation, thromboelastography (TEG) is needed.
  • Responding to an elevated INR by transfusing FFP is a misguided practice which should be abandoned. Cirrhotics rarely have true enzymatic hypocoagulability, so they generally do not benefit from FFP.
  • For patients with cirrhosis and bleeding, repletion of fibrinogen and platelets may be more effective in achieving hemostasis.
  • A subset of patients with advanced cirrhosis appear to have hyperfibrinolysis. Such patients may benefit from tranexamic acid.
  • In the context of a variceal hemorrhage, over-resuscitation may aggravate bleeding by markedly increasing the blood pressure within the varicies.
  • Our general strategy of repleting blood factors individually to target a roughly “euboxic” coagulation panel should be questioned. It is possible that focusing on the overall balance of coagulation and fibrinolysis, rather than individually normalizing each component, may allow for a more flexible and effective approach.
  • For now, the following approach may be reasonable: