Rotational thromboelastometry helped reduce prophylactic blood product use for port insertion in patients with liver...

Plasma exchange (PLEX) is used to treat liver failure patients who have coagulopathy. There is no consensus regarding pre-procedural blood product transfusion prior to PLEX port placement among patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). The primary objective was to study the difference in prophylactic blood product use in patients with ALF and ACLF who had rotational thromboelastometry (ROTEM) done prior to PLEX port insertion (ROTEM group -RG) compared with those patients in whom ROTEM was not done (conventional coagulation group-CG). Secondary objectives were to study local port site-related bleeding events between these groups and the correlation between ROTEM parameters and conventional coagulation tests (CCT), in patients with ALF and ACLF.

We retrospectively analyzed consecutive patients who underwent PLEX for ALF and ACLF using central venous access (11.5 F and 10 F catheter for adult and pediatric patients, respectively) between October 2016 and February 2022. The prophylactic transfusion strategy in CG was based on CCT and RG was based on CCT and ROTEM parameters. Propensity score matching (PSM) was done separately for ALF and ACLF between RG and CG.

Total 88/113 patients with ALF/ACLF underwent PLEX. In PSM matched 77 ALF/108 ACLF patients, prophylactic blood products use was significantly less in RG (18/50 [36%]/12/85 [14%]) compared CG (21/27 [78%]/18/23 [78%]; p < 0.001). Local port site bleeding events were noted in two ACLF patients (one in RG and one in CG) and none in ALF. In ALF/ACLF patients, the correlation between clotting time (CT, ROTEM) and prothrombin time international normalized ratio (PT-INR, CCT) was 0.29/0.35 (weak), respectively, between maximum clot firmness (MCF, ROTEM) and fibrinogen was 0.68/0.76 (strong), respectively, and between maximum clot firmness (MCF, ROTEM) and platelet was 0.56/0.71 (moderate/strong), respectively.

The use of a ROTEM-based transfusion strategy prior to PLEX port insertion helped reduce prophylactic blood product transfusion among patients with ALF and ACLF.