Table 1 Management of perioperative coagulopathy in chronic liver disease

Vitamin K

IV vitamin K can be given for patients who are severely malnourished or have malabsorption, secondary to biliary obstruction, bile salt deficiency, or use of broad spectrum antibiotics.

The recommended dose in 10 mg IV daily for 3 days prior to surgery.

Fresh frozen plasma (FFP)

The correction of INR with FFP has not been shown to decrease the risk of bleeding in cirrhotics. It is not recommended to empirically transfuse FFP for elevated INR or prothrombin time. Excessive use of FFP can lead to significant complications such as volume expansion, infection, and transfusion-associated lung injury (TRALI).

If the patient is clinically bleeding, it is recommended to transfuse FFP, at a dose of 10–15 ml/kg.

Platelets

Platelet transfusion should be considered in active bleeding if platelet levels are below 50,000.

The recommended dose is 1 unit per 10 kg body weight.

Cryoprecipitate

Hypofibrinogenemia (≤ 100 mg/dl) should be corrected with cryoprecipitate.

The recommended dose is one bag (10 units) per 10 kg of body weight.

Tranexemic acid

Tranexemic acid, an anti-fibrinolytic agent, should be used in patients with hyperfibrinolysis diagnosed by thromboelastography or patients with intractable bleeding.

A loading dose of 10 mg/kg is given, repeated three times for 2–8 days.

DDAVP

DDAVP is an analogue of vasopressin. It releases vWF and factor VIII. Despite the high levels of vWF in cirrhosis, DDAVP has been shown to decrease bleeding time in those patients.

The recommended dose is 300 μg IV.

rfVIIa

rfVIIa has a high cost, transient effect, and thrombotic complications. It has been shown to reduce bleeding in the placement of intracranial pressure monitoring devices but not in any other surgical procedure. Its clinical indications are limited.

If used, the dose is 40 μg/kg.