- defined as INR >1.5 due to liver dysfunction
- patients are not ‘auto-anticoagulated’ – they are often in a procoagulant state!
Hemostasis is rebalanced, but at a lower level and thus prone to tipping over into hemorrhage or thrombosis
- decreased Factor 2,7,9,10 and 5 -> anticoagulant effect
- decreased Protein C and S -> procoagulant effect
- decreased ADAMTS13 -> increased platelet microthrombi -> worse liver/ MOF and thrombocytopenia
- decreased plasminogen and alpha2-antiplasmin; increased tissue plasminogen activator and plasmin activiating inhibitor-1 -> mixed fibrinolytic and antifribrinloytic effect
- patients with INR >1.5 due to liver dysfunction are not necessarily at increased risk of bleeding
- avoid prophylactic FFP and platelets
- only give haemostatic agents if actively bleeding
- can use viscoelastic tests such as TEG or thrombin generation assays (+/- thrombomodulin or Protec) to demonstrate hypercoagulability
- consider thromboprophylaxis
References and Links
- Schaden E, Saner FH, Goerlinger K. Coagulation pattern in critical liver dysfunction. Curr Opin Crit Care. 2013 Apr;19(2):142-8. PMID: 23400090.
- Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011 Jul 14;365(2):147-56. PMID: 21751907.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.