肝硬化患者围术期凝血功能管理进展

Advances in Perioperative Coagulation Management for Patients with Liver Cirrhosis

摘要: 肝硬化导致凝血因子与抗凝因子同步减少，形成脆弱的“凝血再平衡”。其特征包括：血小板减少但VWF升高代偿功能、因子VIII升高打破促凝–抗凝平衡、纤溶系统紊乱等。这种平衡易被手术应激打破，引发出血或血栓风险。围术期凝血管理应摒弃单纯依赖传统凝血参数(如INR、血小板计数)进行预防性纠正的策略，转而通过动态评估止血状态、优化风险因素及个体化干预，维持再平衡。围术期管理中避免肝毒性药物，积极控制感染、肾衰竭等诱因，选用TEG/ROTEM动态评估全血凝血过程，逐步建立肝硬化分期特异的参考范围，依据TEG结果指导成分输血以减少输血相关容量负荷及控制性低中心静脉压。此外，应根据手术类型进行风险分层，并对重大手术制定个体化管理方案。本篇综述强调，肝硬化患者凝血状态呈动态再平衡，其稳定性受肝病分期及并发症影响。围术期成功管理依赖多维度综合评估与动态功能监测，而非孤立、静态的凝血实验室参数。

Abstract: Cirrhosis leads to a simultaneous reduction in both coagulation factors and anticoagulant factors, resulting in a fragile “rebalanced hemostasis.” Key features include thrombocytopenia with compensatory elevation of von Willebrand factor (VWF), increased factor VIII that disrupts the procoagulant-anticoagulant equilibrium, and disturbances in the fibrinolytic system. This delicate balance is easily disrupted by surgical stress, posing risks of bleeding or thrombosis. Perioperative coagulation management should move away from strategies that rely solely on conventional coagulation parameters (such as INR and platelet count) for prophylactic correction. Instead, a dynamic assessment of hemostatic status, optimization of risk factors, and individualized interventions should be adopted to maintain this rebalance. During the perioperative period, hepatotoxic medications should be avoided, and triggers such as infection and renal failure must be actively controlled. Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) should be used to dynamically evaluate whole-blood coagulation. Establishing stage-specific reference ranges for cirrhosis and guiding component transfusion based on TEG results can help reduce transfusion-related volume overload and facilitate controlled low central venous pressure. Furthermore, risk stratification should be performed according to the type of surgery, with individualized management plans developed for major procedures. This review highlights that the coagulation status in cirrhotic patients is characterized by a dynamic rebalance, the stability of which is influenced by the stage of liver disease and associated complications. Successful perioperative management relies on multidimensional comprehensive assessment and dynamic functional monitoring, rather than isolated and static conventional coagulation laboratory parameters.