LAUSR

The study by Vibede et al. raises a number of important points regarding the use of blood products and the management of coagulation disturbances that require further emphasis. As previously demonstrated by Holland and Brooks, Fresh Frozen Plasma (FFP) has limited effect in correcting coagulation disturbances. They demonstrated a significant change in the INR when it was above 1.7 in only 50% of patients. Silbern et al., demonstrated similar effects over 30 years ago yet the practice has continued. The conventional measures of coagulation – PT and INR – are in vitro tests developed for the monitoring of heparin and Vitamin K antagonists, respectively. They are a reflection of coagulation up to the so-called 0thrombin burst0 but do not reflect in vivo coagulation. Nowhere is this better demonstrated than in patients with liver cirrhosis. Alteration of the normal procoagulant and anti-coagulant factors leads to an invalidation of the usual clotting parameters. The use of dynamic tests such as thromboelastography reflect the in vitro coagulation and allow an individualized and precise management of clotting disturbances. A more widespread adoption of this process is important to reduce the inappropriate administration of FFP which ranges up to 83% and as Segel and Dzik have described results from three false assumptions: (1) Elevation of PT/INR increases periprocedural bleeding risk, (2) Prophylactic FFP corrects the abnormal results, and (3) FFP reduces bleeding events. Finally, it must be realized that the administration of FFP is not benign and presents several risks including allergic reactions, transfusionassociated circulatory overload, and transfusionrelated acute lung injury. A major change in approach is needed, as demonstrated by Vibede et al., in the management of coagulation with a greater use of thromboelastography. The necessary financial investment will likely be offset by a more judicious use of blood products, not just FFP.