Despite running contrary to dogma, this is actually fairly straightforward. If a patient cannot be helped by a particular therapy, they can only be harmed. Therefore, it follows that if patients with ESLD are in a rebalanced state of pro- and anti-hemostatic factors without an innately increased bleeding risk, there remain only the harms associated with FFP transfusion.

Most of the evidence in support of this statement has emerged from case series utilizing clot-formation assays such as thromboelastometry (ROTEM) or thromboelastography (TEG). For example, one pilot study found all but one of 55 patients with elevated INR (≥1.3) in an intensive care unit had, in fact, normal coagulation when tested by ROTEM.⁴ Subsequently, these authors were able to obviate their typical practice of periprocedural transfusion of four units of FFP, and no bleeding complications were observed.

The PT and INR only narrowly reflect one portion of the coagulation cascade, do not reflect a holistic view of the ability to clot, and do not accurately represent bleeding risk.

Specific to cirrhotics, a small randomized trial divided patients into two cohorts: preprocedural transfusion using an INR-based “standard of care” and an alternative TEG-guided pathway.⁵ The mean INR in the study was just under 2, and while only half of the cohort underwent procedures with an elevated bleeding risk, the TEG-guided strategy dramatically reduced FFP and platelet transfusions without any difference in subsequent periprocedural RBC transfusion.

These findings are critically important because a growing body of evidence reflects previously underrecognized risks related to transfusion. Transfusion-associated adverse events cause significant morbidity and mortality while consuming limited resources. Transfusion-associated circulatory overload and transfusion-related lung injury are reported to occur in 1 in 20 to 1 in 50 critically ill patients receiving transfusion and are major causes of transfusion-related fatalities. Transfusion-related immunomodulation also increases the susceptibility to nosocomial infections and sepsis in the critically ill.

Furthermore, in patients with cirrhosis and upper gastrointestinal bleeding (UGIB), aggressive resuscitation is almost certainly harmful. The typical dose required to “correct” an elevated INR of 4 units of FFP adds approximately a liter of high-osmotic intravascular volume. This has the effect of increasing portal venous pressures and can thereby precipitate worsening gastrointestinal hemorrhage. These same harms from transfusion are also seen in RBC transfusions in acute UGIB. In a prospective trial, a restrictive transfusion threshold of 7 g/dL conferred a survival advantage over a more liberal strategy using a threshold of 9 g/dL.⁶ This advantage was maintained in the third of patients with cirrhosis and UGIB and those with variceal bleeds, reducing mortality from 18 percent to 11 percent.