Pre-operative Management of Coagulopathy in Cirrhotic Patient Requiring Urgent Laparotomy
Fresh frozen plasma (FFP) is the most appropriate next step prior to urgent laparotomy in this patient with significant coagulopathy (INR 2.0, PT 17 seconds) and cirrhosis requiring emergency surgery for perforated peptic ulcer. 1
Rationale for FFP Administration
FFP contains all soluble coagulation factors including the labile factors V and VIII, making it the appropriate choice for correcting multiple factor deficiencies in liver disease 1
In actively bleeding patients with INR > 1.5, FFP is specifically indicated, and this patient requires urgent surgery for a perforated ulcer which carries high bleeding risk 1
The recommended therapeutic dose is 15 ml/kg, which should be administered urgently prior to surgical intervention 1
FFP should be ABO-compatible with the patient; if blood group is unknown, group AB FFP should be used 1
Why Not the Other Options
Cryoprecipitate
- Cryoprecipitate is primarily indicated for hypofibrinogenemia (fibrinogen < 1.5 g/L) during major hemorrhage 1
- This patient's coagulopathy is due to multiple factor deficiencies from cirrhosis, not isolated fibrinogen deficiency 1
- Cryoprecipitate does not correct INR or PT abnormalities effectively 1
Platelets
- While the platelet count of 90 × 10⁹/L is below normal, prophylactic platelet transfusion for procedures in critically ill patients should be avoided unless there is high risk of catastrophic bleeding 2
- The primary hemostatic defect in this patient is coagulopathy (elevated INR/PT), not thrombocytopenia 1
- Platelet transfusion alone will not correct the coagulation factor deficiencies 2
Packed Red Blood Cells
- While the hemoglobin of 90 g/L is low, immediate correction of anemia is not the priority before surgery 3
- The life-threatening issue is the coagulopathy that will cause uncontrolled bleeding during laparotomy 1
- PRBCs can be administered intraoperatively or postoperatively as needed 3
Important Caveats
FFP has limited efficacy in cirrhosis due to "balanced hemostasis" where both pro- and anticoagulant factors are reduced, but it remains indicated for urgent surgery with active bleeding risk 1
Do not delay surgery for prolonged attempts at normalization of coagulation parameters; administer FFP while preparing for urgent laparotomy 1
Monitor for volume overload as FFP volume is approximately 300 ml per bag, and multiple units may be needed 1
Consider intraoperative blood product support as this patient will likely require additional FFP, platelets, and PRBCs during and after surgery 3