TEG-based transfusion protocol is associated with decreased blood product use without increased risk of hemoperitoneum.

BACKGROUND: Thromboelastography (TEG) informs the need for blood product transfusions to prevent procedural bleeding complications in patients with cirrhosis. We aimed to evaluate the impact of using a TEG-based transfusion protocol on blood product utilization before paracentesis and the post-paracentesis hemoperitoneum (PPH) incidence. METHODS: We conducted an ambispective analysis of patients with cirrhosis who underwent paracentesis from 2017 to 2021. In May 2019, we enacted a TEG-based transfusion protocol to guide pre-paracentesis blood product use. Patients with platelets < 20,000 or international normalized ratio ≥ 4 underwent TEG and received blood products if r value > 10 min or MA <30 mm. Patients were divided into pre-TEG and post-TEG protocol cohorts based on the date of paracentesis. Pre-paracentesis blood product transfusions in the form of platelets, fresh frozen plasma, and cryoprecipitates were recorded. PPH was defined as a decrease in hemoglobin of ≥1 g and the presence of blood on diagnostic imaging and/or the need for therapeutic intervention. RESULTS: A total of 483 patients underwent 1281 paracenteses. The main etiologies of cirrhosis were alcohol (43%) and NASH (25%), and the mean MELD-sodium was 22±6. Pre-TEG and post-TEG protocol cohort sizes were similar: 253 patients and 607 paracenteses versus 230 patients and 674 paracenteses. After TEG-protocol implementation, blood product transfusions decreased significantly (228 vs. 49 products, p<0.001) with associated cost savings. One patient in each cohort developed PPH. CONCLUSION: Implementation of a pre-paracentesis TEG-based transfusion protocol for patients with cirrhosis successfully resulted in decreased blood product use with no associated increase in incidence of PPH.

Prevalence and clinical impact of alcohol withdrawal syndrome in alcohol-associated hepatitis and the potential role of prophylaxis: a multinational, retrospective cohort study.

Background: The prevalence and impact of alcohol withdrawal syndrome (AWS) in patients with alcohol-associated hepatitis (AH) are unknown. In this study, we aimed to investigate the prevalence, predictors, management, and clinical impact of AWS in patients hospitalized with AH. Methods: A multinational, retrospective cohort study enrolling patients hospitalized with AH at 5 medical centres in Spain and in the USA was performed between January 1st, 2016 to January 31st, 2021. Data were retrospectively retrieved from electronic health records. Diagnosis of AWS was based on clinical criteria and use of sedatives to control AWS symptoms. The primary outcome was mortality. Multivariable models controlling for demographic variables and disease severity were performed to determine predictors of AWS (adjusted odds ratio [OR]) and the impact of AWS condition and management on clinical outcomes (adjusted hazard ratio [HR]). Findings: In total, 432 patients were included. The median MELD score at admission was 21.9 (18.3-27.3). The overall prevalence of AWS was 32%. Lower platelet levels (OR = 1.61, 95% CI 1.05-2.48) and previous history of AWS (OR = 2.09, 95% CI 1.31-3.33) were associated with a higher rate of incident AWS, whereas the use of prophylaxis decreased the risk (OR = 0.58, 95% CI 0.36-0.93). The use of intravenous benzodiazepines (HR = 2.18, 95% CI 1.02-4.64) and phenobarbital (HR = 2.99, 95% CI 1.07-8.37) for AWS treatment were independently associated with a higher mortality. The development of AWS increased the rate of infections (OR = 2.24, 95% CI 1.44-3.49), the need for mechanical ventilation (OR = 2.49, 95% CI 1.38-4.49), and ICU admission (OR = 1.96, 95% CI 1.19-3.23). Finally, AWS was associated with higher 28-day (HR = 2.31, 95% CI 1.40-3.82), 90-day (HR = 1.78, 95% CI 1.18-2.69), and 180-day mortality (HR = 1.54, 95% CI 1.06-2.24). Interpretation: AWS commonly occurs in patients hospitalized with AH and complicates the hospitalization course. Routine prophylaxis is associated with a lower prevalence of AWS. Prospective studies should determine diagnostic criteria and prophylaxis regimens for AWS management in patients with AH. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Fusobacterium Bacteremia Causing Hepatic Abscess in a Patient With Diverticulitis.

Fusobacterium, a gram-negative non-spore-forming anaerobe, is a common inhabitant of the oral cavity; however, it is not typically found in other organ systems. The occurrence of a hepatic abscess associated with this organism is rare. We present a patient with recurrent diverticulitis with left upper quadrant abdominal pain, and abdominal imaging revealed a hepatic abscess in addition to sigmoid diverticulitis. Further investigations led to an unusual culprit; Fusobacterium nucleatum.

COVID-19 Infection Presenting as an Isolated Severe Acute Liver Failure.

The clinical features of severe acute respiratory syndrome-coronavirus disease 2019 (SARS-COVID-19) infection range from mild upper respiratory symptoms to severe acute respiratory failure. Among other less common features are diarrhea, nausea, vomiting, elevated liver enzymes, and acute kidney injury. We present a case of a 49-year-old female with no preexisting liver disease who presented with weakness and dizziness for one week. Initial investigations revealed acute liver failure (ALF) and positive COVID-19 on polymerase chain reaction (PCR) testing. The patient did not have any upper or lower respiratory symptoms, and extensive workup to look for other etiologies of acute liver failure was unremarkable. She eventually deteriorated to decompensated liver failure and was transitioned to comfort measures only. Liver injury is a well-documented phenomenon associated with COVID-19 infection. Some of the common pathophysiological mechanisms include direct liver injury, immune-mediated liver damage due to the severe inflammatory response, ischemic injury, endothelial disruption, and coagulopathy. Our case uniquely highlights that SARS-COVID-19 infection may have the potential to solely affect hepatocytes without the classic severe acute respiratory distress syndrome. This case demonstrates that a diagnosis of COVID-19 may be considered if no other etiology of ALF is identified.