No bleeding during a dialysis catheter insertion in a patient with INR 3.2 due to acute liver dysfunction

Abstract

We report a case of a 61-year-old female admitted to the intensive care unit (ICU) with circulatory failure, acute liver dysfunction and stage 3 acute kidney injury (AKI) secondary to severe acute pancreatitis (SAP). Despite a markedly elevated international normalized ratio (INR >3) and uremia (urea >100 mg dL^-1), a dialysis catheter was inserted without any bleeding. Viscoelastic hemostatic assay (VHA) demonstrated preserved clot propagation and firmness and impaired clot initiation. Based on ROTEM results and absence of signs of clinical bleeding, we opted against prophylactic transfusion of fresh frozen plasma (FFP) and proceeded with catheter placement. No bleeding was observed during or after the procedure. This case supports growing evidence that conventional coagulation tests (CCTs) like INR are unreliable predictors of bleeding in acute liver failure. VHAs offer a global and functional assessment of hemostasis, revealing rebalanced or hypercoagulable profiles otherwise masked by CCTs. Current guidelines increasingly discourage routine FFP transfusion prior to invasive procedures, advocating individualized risk assessment. Our report contributes to ongoing discussion about optimizing transfusion practices and procedural safety in critically ill patients with elevated INR and supports the broader integration of VHAs into ICU decision-making.