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Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand.

  • Warrillow, Stephen1, 2
  • Fisher, Caleb1
  • Tibballs, Heath1
  • Bailey, Michael2, 3
  • McArthur, Colin4, 5
  • Lawson-Smith, Pia5
  • Prasad, Bheemasenachar6
  • Anstey, Matthew7
  • Venkatesh, Bala8
  • Dashwood, Gemma8
  • Walsham, James8
  • Holt, Andrew9
  • Wiersema, Ubbo9
  • Gattas, David10
  • Zoeller, Matthew10
  • Garcia Alvarez, Mercedes11
  • Bellomo, Rinaldo1, 2, 12, 13, 14
  • 1 Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia. , (Australia)
  • 2 Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia. , (Australia)
  • 3 Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia. , (Australia)
  • 4 Medical Research Institute of New Zealand, Auckland, New Zealand. , (New Zealand)
  • 5 Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand. , (New Zealand)
  • 6 South Metropolitan Health Service, Rockingham, Western Australia, Australia. , (Australia)
  • 7 Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. , (Australia)
  • 8 Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia. , (Australia)
  • 9 Department of Intensive Care, Flinders Medical Centre, Adelaide, South Australia, Australia. , (Australia)
  • 10 Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia. , (Australia)
  • 11 Department of Anesthesiology and Pain Medicine, Hospital Santa Creu i Sant Pau, University of Barcelona, Barcelona, Spain. , (Spain)
  • 12 Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia. , (Australia)
  • 13 Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Australia. , (Australia)
  • 14 Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia. , (Australia)
Published Article
Journal of Gastroenterology and Hepatology
Wiley (Blackwell Publishing)
Publication Date
Nov 05, 2019
DOI: 10.1111/jgh.14876
PMID: 31689724


To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62 s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P < 0.0001). Median initial lowest platelet count was 83 (IQR 41-122) × 109 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies. © 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

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