Patients with severe liver disease may bleed for a variety of reasons. Careful use of blood products and drugs can often control the bleeding in most patients.
Hemostatic problems in patients with severe liver disease:
(1) prolongation of the PT and PTT (due to vitamin K deficiency, failure of hepatic synthesis, hypofibrinogenemia, DIC)
(2) hypofibrinogenemia (dysfibrinogenemia. DIC)
(3) thrombocytopenia (sequestration in spleen, DIC, sepsis, decreased production from bone marrow)
(4) platelet dysfunction
Problem
Goal
Therapy
prolonged PT
within 3 seconds of upper limit of normal
(1) parenteral vitamin K
(2) FFP 12-20 mL per kg body weight
(3) prothrombin complex if the patient is unable to handle the FFP volume
fibrinogen < 150 mg/dL
> 150 mg/dL
cryoprecipitate
platelet count < 100,000 per µL
> 100,000 per µL
platelet concentrates
abnormal bleeding time
reduce to or near normal
desmopressin acetate 0.3 µg/kg IV
where:
• The dose of FFP represents about 33-50% of an adult's plasma volume.
• Dosing of products in the bleeding patient has to be continuously adjusted since s/he may not be stable.
• Desmopressin = diamino-8-D-arginine vasopressin. It increases the high molecular weight multimers of von Willebrand's factor, which appears to be beneficial in reversing an elevated bleeding time.
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