Flea Bytes: Paracentesis and Bleeding Risk

AASLD Practice Guidelines:

Bleeding from paracentesis is relatively uncommon. The routine use of FFP or platelet transfusion is not recommended before paracentesis. You should avoid any engorged veins as most bleeding occurs from the venous circulation.

It may be reasonable to correct patients who have bled before with paracentesis, have hyperfibrinolysis (as they wouldn’t be able to clot effectively due to factor depletion), patients with evidence of overt bleeding from mucosa (epistaxis, vaginal bleeding, etc), or have history of bleeding at puncture sites (like IVs or blood draws).

Reference:

“Management of adult patients with ascites due to cirrhosis: an update.” Runyon BA. Hepatology. 2009;49(6):2087 

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Flea Bytes: Differentiating Synthetic Dysfunction from DIC in Liver Disease

You can check factor VIII levels because they tend to be normal to increased in liver disease as it is not produced by the liver, but rather endothelial cells. In DIC all of the factors are consumed, so factor VIII levels will be low.

The other test that maybe helpful is checking a d-dimer. The d-dimer tends to be significantly increased in DIC due to profound fibrinolysis. However, d-dimer levels may also be elevated in liver disease, but usually only mildly elevated.

Flea Bytes: Child-Pugh Classification in Cirrhosis

2 scores really come to mind when discussing prognostication in cirrhosis: Child-Pugh Classification (Child-Turcotte-Pugh) or the Model for End Stage Liver Disease.

The Child-Pugh classification predicted operative mortality in the transection of the esophagus for the treatment of bleeding varices. A study was published by Dr Pugh in the British Journal of Surgery in 1973. The model they used to assess the severity of liver disease was based on the work of Child in 1964, but added the prothrombin time and eliminated the assessment of nutrition. See the table below for score calculation.

The case series presented the outcomes of 38 patients who were admitted to King’s College Hospital in London from 1966-1972. The calculated the score for all the patients. The authors found a 29% mortality in Grade A, 28% mortality in Grade B, and found a whopping 88% mortality in Grade C. In this study only 4 patients with Grade C left the hospital and none survived to 6 months.