It is important to remember that, despite abnormal laboratory studies, the most common cause of bleeding in liver disease is a mechanical defect (hole in vessel). Thus, evaluation in patients with severe bleeding should be aimed at identifying sites of bleeding. Many patients will have dramatic gastrointestinal bleeding due to bleeding varices or gastric ulcers. In these situations replacement of coagulation factors provides an "adjunctive therapy" role to definitive therapy. Except for certain coagulation defects (thrombocytopenia, fibrinolysis), corrections of mild-to moderate coagulation defects in the severely bleeding patient are probably not important and correction of severe coagulation defects is impossible.
An initial screen of the bleeding patient should consist of the hematocrit, platelet count, PT-INR/aPTT, fibrinogen, D-Dimer and euglobulin clot lysis time (Table 9.2). Since DIC can commonly complicate liver disease, evaluation for DIC should be done on unstable patients with liver disease.
In the rapidly bleeding patient the "magic five" (HCT, PT-INR, aPTT, platelets fibrinogen) should be checked every few hours to guide therapy (Table 9.3). Ideally therapeutic goals should be:
• Protime >INR 2.0 and aPTT abnormal—give 2 units of FFP.
• Platelets <50-75K—give 6 Platelet concentrates or one plateletpheresis unit
• Fibrinogen <125 mg/dl—give 10 units of cryoprecipitate.
However, it is often difficult to lower the protime in patients with severe liver disease due to the short half-life of factor VII and the minimal changes one achieves with FFP (increase of 5%/unit of FFP for all clotting factors). Consequently, therapy should not be aimed at complete correction of abnormal laboratory values. Over-zealous attempts to totally correct the INR are unproductive and will result in volume overload. Also, the increased plasma volume may increase portal pressures, thereby increasing the risk of more bleeding. Keeping the platelet count above 50,000/
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