Visceral and transplant surgery

Despite PT, aPTT and INR indicating coagulopathy in chronic liver disease (CLD), global coagulation tests (thrombin generation and VHA) suggest that haemostasis is balanced in stable CLD. C

Mild-to-moderate prolongation of the preoperative PT and INR do not predict bleeding in patients with CLD. C

We recommend that, in acute liver failure, moderately elevated INR should not be corrected before invasive procedures, with the exception of intracranial pressure monitor insertion. 1C

Fluid restriction, phlebotomy, vasopressors and transfusion protocols may be associated with low transfusion rates during orthotopic liver transplant (OLT). C

We recommend a low CVP and restrictive fluid administration during liver surgery to reduce bleeding. 1B

We recommend tranexamic acid for treatment of fibrinolysis (evident from microvascular oozing or VHA clot lysis measurement) but not for routine prophylaxis. Marginal grafts (e.g. donation after cardiac death) increase the risk of fibrinolysis postreperfusion. 1C

We suggest that tranexamic acid should be considered in cirrhotic patients undergoing liver resection. 2C

Acute upper gastrointestinal bleeding

We recommend that acute variceal bleeding should be managed by a multidisciplinary team. A specific multimodal protocol for upper gastrointestinal haemorrhage should be available. 1C

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) can be suggested as an option for rescue therapy after initial medical and endoscopic therapy fail. 2B

We recommend early interventional endoscopy and the immediate use of vasopressors (somatostatin or terlipressin) to reduce bleeding. 1B

Tranexamic acid reduces mortality but not re-bleeding. B

Coagulopathy and renal disease

Point-of-care tests of platelet function and bleeding time provide no reliable platelet function assessment in uraemia and no prediction of bleeding in this setting. C

We suggest that conjugated oestrogen therapy should be used in uraemia. 2C

We suggest that DDAVP should be considered for reducing bleeding during surgery and for managing acute bleeding in uraemic patients. 2C