How to correct coagulopathy in a patient with septic shock and decompensated cirrhosis?

Management of Coagulopathy in Septic Shock with Decompensated Cirrhosis

Do not routinely correct laboratory coagulation abnormalities with fresh frozen plasma in patients with septic shock and decompensated cirrhosis unless there is active bleeding or a planned invasive procedure. 1

Understanding the Coagulopathy

• Patients with decompensated cirrhosis have a rebalanced coagulation system with simultaneous reductions in both procoagulant and anticoagulant factors, meaning traditional tests like INR and PT poorly correlate with actual bleeding risk 1, 2
• The INR measures only procoagulant factors (I, II, V, VII, X) and does not account for anticoagulant deficiencies, creating a misleading picture of bleeding risk 1
• Viscoelastic testing (TEG or rotational thromboelastometry) provides superior functional assessment of coagulation in cirrhosis by measuring platelet function, hyperfibrinolysis, and clot stability in real-time, though optimal cutoffs for transfusion decisions remain undefined 1

Evidence-Based Approach to Correction

Fresh Frozen Plasma (FFP)

• The Surviving Sepsis Campaign explicitly recommends against using FFP to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures 1
• FFP transfusion frequently fails to correct PT/INR in non-bleeding patients with mild abnormalities and carries significant risks including volume overload, transfusion reactions, and worsening portal hypertension 1, 2
• No studies demonstrate benefit of correcting coagulation abnormalities in non-bleeding cirrhotic patients 1

Platelet Transfusion

• Administer platelets prophylactically only when counts are <10,000/mm³ in the absence of bleeding 1
• Consider prophylactic transfusion when counts are <20,000/mm³ if significant bleeding risk exists 1
• For active bleeding, surgery, or invasive procedures, maintain platelet counts ≥50,000/mm³ 1

Antithrombin and Other Agents

• Do not use antithrombin for treatment of septic shock in cirrhosis—a phase III trial showed no mortality benefit and increased bleeding risk when combined with heparin 1
• The Surviving Sepsis Campaign makes no recommendation regarding thrombomodulin or heparin use 1

Active Bleeding Management

When active bleeding occurs in this population:

• Prioritize hemodynamic resuscitation with crystalloids (balanced solutions preferred) using a restrictive strategy to avoid worsening portal hypertension 1, 3, 4
• Maintain restrictive transfusion threshold with hemoglobin target of 7-9 g/dL unless myocardial ischemia, severe hypoxemia, or ongoing hemorrhage present 1, 5
• For variceal bleeding specifically, immediately initiate vasoactive drugs (octreotide, terlipressin, or somatostatin) even before endoscopic confirmation 5, 3, 4
• Administer antibiotic prophylaxis immediately (ceftriaxone 1g IV daily preferred in decompensated cirrhosis) for up to 7 days 5, 3, 4

Pre-Procedural Considerations

For planned invasive procedures:

• Use viscoelastic testing (if available) rather than INR/PT to guide transfusion decisions 1
• Consider FFP, cryoprecipitate, or four-factor prothrombin complex concentrate only for documented functional coagulation defects on viscoelastic testing, though optimal cutoffs remain undefined 1
• Recombinant Factor VIIa is FDA-approved for congenital Factor VII deficiency and hemophilia with inhibitors but not indicated for routine coagulopathy correction in cirrhosis 6

Critical Pitfalls to Avoid

• Avoid overtransfusion of crystalloids—excessive volume increases portal pressure, worsens coagulopathy, and increases rebleeding risk in cirrhosis 1, 3
• Do not use hydroxyethyl starch for resuscitation—meta-analyses show increased mortality compared to balanced crystalloids or albumin in sepsis 1
• Recognize that cirrhotic patients may also be at increased risk of thrombosis despite abnormal laboratory values, making indiscriminate correction potentially harmful 2, 7
• Avoid nephrotoxic drugs, large-volume paracentesis, and beta-blockers during acute septic shock as these worsen circulatory dysfunction 7

Albumin Considerations

• Albumin may be considered for resuscitation in septic shock with cirrhosis—single-center RCTs showed higher rates of shock reversal and improved 1-week survival compared to crystalloids, though with increased pulmonary complications 1
• Albumin is specifically indicated for large-volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome 1
• Avoid targeting specific albumin levels (e.g., maintaining >3 g/dL) as this increases pulmonary edema and fluid overload without improving outcomes 1

Hemodynamic Monitoring

• Maintain mean arterial pressure ≥65 mmHg with vasopressors (norepinephrine first-line) while avoiding over-resuscitation 1
• Use dynamic hemodynamic monitoring (stroke volume variation, passive leg raise, or TTE) to guide fluid administration rather than static measurements 1
• Monitor for signs of circulatory dysfunction and multiple organ failure, which are common in this population 8, 9, 7