Introduction: Thromboelastography (TEG) is a blood test used to evaluate hemostasis by measuring platelet function and coagulation efficacy. Patients with cirrhosis can have dysfunctional clotting abilities that are not accurately assessed by standard coagulation testing such as international normalized ratio (INR) and platelet count, and may be subjected to harm from over-transfusion. The aim of our study is to compare the utilization of blood products in patients with cirrhosis undergoing procedures based on the standard coagulation tests versus TEG, and the associated adverse outcome.
Methods: We retrospectively identified patients with cirrhosis who had a TEG drawn prior to an inpatient procedure. Data from the TEG and standard coagulation tests were gathered along with transfused blood products, type of procedures done, and post-procedural outcomes. This data was used to assess the appropriateness of transfusion based on TEG parameters versus standard coagulation tests.
Results: A total of 36 patients met inclusion criteria. Out of 36 patients with both a platelet count and a TEG, 19 (52.8%) followed TEG-based transfusion strategy, while 17 (47.2%) did not. Of the 33 patients with both an INR and a TEG, 23 (69.7%) were transfused based on TEG. 17 patients with both fibrinogen and a TEG, 12 (70.6%) received appropriate transfusion therapy per TEG criteria. Out of 36 patients, 15 (41.7%) required post-procedural transfusion of packed red blood cells and only 5 (33.3%) were transfused in a TEG-directed manner prior to the procedure.
Discussion: The majority of post-procedural bleeding events occurred in patients not transfused in a TEG-based approach prior to the procedure. Interestingly, clinicians were not providing TEG-directed transfusion care consistently. It is unclear whether this was related to a lack of knowledge associated with interpretation of TEG or due to other variables. As blood products are limited, they should be used judiciously. Furthermore, excessive transfusion in patients with cirrhosis may lead to adverse outcomes.
To improve TEG utilization, we propose a system-wide lecture to advance clinician knowledge of TEG as a strategy to minimize transfusions. An automated reminder in the electronic medical record to facilitate ordering of TEG will also be implemented. A follow up study will also be conducted to determine whether these interventions improved TEG-directed transfusion and to provide a larger cohort to determine the efficacy and safety profile of TEG-directed transfusion.
