Jonathan G Stine1,2,3, Nicolas M Intagliata4, Neeral L Shah4, Ton Lisman5, Francesco Violi6, Stephen H Caldwell4, Curtis K Argo4. 1. Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA. jstine@pennstatehealth.psu.edu. 2. Department of Public Health Sciences, The Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA. jstine@pennstatehealth.psu.edu. 3. Pennsylvania State University Milton S. Hershey Medical Center Liver Center, Hershey, PA, USA. jstine@pennstatehealth.psu.edu. 4. Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA. 5. Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 6. Department of Internal and Specialized Medicine, Sapienza University of Rome, Rome, Italy.
Abstract
INTRODUCTION AND AIM: Hemostatic disorders in chronic liver disease and cirrhosis show continued expansion of research efforts. However, clinical decision making is often practiced on an individual patient level as consensus guidelines are lacking. We aimed to better assess individual day-to-day clinical practice through gauging clinicians' responses to common clinical scenarios. MATERIALS AND METHODS: A series of ten clinical scenarios (seven procedural coagulation and three thrombosis management) were posed to conference attendees utilizing real-time polling software (Poll Everywhere). Responses were binomial and were submitted as "Agree" or "Disagree." Results were displayed real time following a standardized response period and an open-forum discussion ensued between conference faculty and attendees following response submission. RESULTS: Twenty conference attendees participated in the clinical scenario plenary session. In general, agreement rates were high. All but one of the ten clinical scenarios had ≥ 70% agreement. Agreement was based both on procedural risk, with greatest agreement seen for low-risk procedures (80-93%), and on peri-procedural coagulation parameters of platelet count and fibrinogen level where > 50,000μ/L and 120 mg/dL were the most agreed upon thresholds, respectively. 75-95% agreement was reached when surveying the need for anticoagulation for mesenteric vein thrombosis in liver transplant candidates; slightly less (71%) agreement was found when deciding to proceed with anticoagulation in non-liver transplant candidates with mesenteric vein thrombosis. CONCLUSIONS: While large-scale, methodologically rigorous randomized controlled trials are lacking to guide clinical decision making in patients with coagulation disorders and chronic liver disease, consensus expert opinion regarding mitigating peri-procedural bleeding risk and treatment of thrombosis appears consistent and strong.
INTRODUCTION AND AIM: Hemostatic disorders in chronic liver disease and cirrhosis show continued expansion of research efforts. However, clinical decision making is often practiced on an individual patient level as consensus guidelines are lacking. We aimed to better assess individual day-to-day clinical practice through gauging clinicians' responses to common clinical scenarios. MATERIALS AND METHODS: A series of ten clinical scenarios (seven procedural coagulation and three thrombosis management) were posed to conference attendees utilizing real-time polling software (Poll Everywhere). Responses were binomial and were submitted as "Agree" or "Disagree." Results were displayed real time following a standardized response period and an open-forum discussion ensued between conference faculty and attendees following response submission. RESULTS: Twenty conference attendees participated in the clinical scenario plenary session. In general, agreement rates were high. All but one of the ten clinical scenarios had ≥ 70% agreement. Agreement was based both on procedural risk, with greatest agreement seen for low-risk procedures (80-93%), and on peri-procedural coagulation parameters of platelet count and fibrinogen level where > 50,000μ/L and 120 mg/dL were the most agreed upon thresholds, respectively. 75-95% agreement was reached when surveying the need for anticoagulation for mesenteric vein thrombosis in liver transplant candidates; slightly less (71%) agreement was found when deciding to proceed with anticoagulation in non-liver transplant candidates with mesenteric vein thrombosis. CONCLUSIONS: While large-scale, methodologically rigorous randomized controlled trials are lacking to guide clinical decision making in patients with coagulation disorders and chronic liver disease, consensus expert opinion regarding mitigating peri-procedural bleeding risk and treatment of thrombosis appears consistent and strong.
Authors: M A Yerdel; B Gunson; D Mirza; K Karayalçin; S Olliff; J Buckels; D Mayer; P McMaster; J Pirenne Journal: Transplantation Date: 2000-05-15 Impact factor: 4.939
Authors: Ton Lisman; Tamara N Bongers; Jelle Adelmeijer; Harry L A Janssen; Moniek P M de Maat; Philip G de Groot; Frank W G Leebeek Journal: Hepatology Date: 2006-07 Impact factor: 17.425
Authors: Maria Assunta Zocco; Enrico Di Stasio; Raimondo De Cristofaro; Marialuisa Novi; Maria Elena Ainora; Francesca Ponziani; Laura Riccardi; Stefano Lancellotti; Angelo Santoliquido; Roberto Flore; Maurizio Pompili; Gian Lodovico Rapaccini; Paolo Tondi; Giovanni Battista Gasbarrini; Raffaele Landolfi; Antonio Gasbarrini Journal: J Hepatol Date: 2009-04-23 Impact factor: 25.083