Management of coagulopathy among patients with cirrhosis undergoing upper endoscopy and paracentesis: Persistent gaps and areas of consensus in a multispecialty Delphi

作者：Elliot B. Tapper, Matthew A. Warner, Rajesh P. Shah, Juliet Emamaullee, Nancy M. Dunbar, Michelle Sholzberg, Jacqueline N. Poston, Robin J. Soto, Ammar Sarwar, Anjana Pillai, Karina Reyner, Shivang Mehta, Marwan Ghabril, Timothy R. Morgan, Stephen H. Caldwell · 发表于：Hepatology · 年份：2024 · DOI：10.1097/hep.0000000000000856 · 被引用次数：11 · 研究领域：Liver Disease and Transplantation、Enhanced Recovery After Surgery、Pituitary Gland Disorders and Treatments

Patients with cirrhosis have abnormal coagulation indices such as a high international normalized ratio and low platelet count, but these do not correlate well with periprocedural bleeding risk. We sought to develop a consensus among the multiple stakeholders in cirrhosis care to inform process measures that can help improve the quality of the periprocedural management of coagulopathy in cirrhosis. We identified candidate process measures for periprocedural coagulopathy management in multiple contexts relating to the performance of paracentesis and upper endoscopy. An 11-member panel with content expertise was convened. It included nominees from professional societies for interventional radiology, transfusion medicine, and anesthesia as well as representatives from hematology, emergency medicine, transplant surgery, and community practice. Each measure was evaluated for agreement using a modified Delphi approach (3 rounds of rating) to define the final set of measures. Out of 286 possible measures, 33 measures made the final set. International normalized ratio testing was not required for diagnostic or therapeutic paracentesis as well as diagnostic endoscopy. Plasma transfusion should be avoided for all paracenteses and diagnostic endoscopy. No consensus was achieved for these items in therapeutic intent or emergent endoscopy. The risks of prophylactic platelet transfusions exceed their benefits for outpatient diagnostic paracentesis and diagnostic endosopies. For the other p...