The assessment of post-procedural bleeding risk in cirrhosis remains a clinical challenge due to the lack of precise predictive tools and its high associated mortality. Although guidelines recommend a restrictive transfusion policy, adherence remains low, with a high rate of prophylactic transfusions despite unclear benefits. This multicenter, prospective, and observational study will evaluate the utility of ROTEM in bleeding risk stratification for cirrhotic patients with significant abnormalities in conventional hemostasis tests undergoing high-risk invasive procedures. The primary objective is to establish cut-off values with a high negative predictive value, optimizing transfusion decisions and reducing unnecessary blood product use. Additionally, the study will analyze the relationship between ROTEM, inflammation biomarkers, and coagulation factors, along with a cost-effectiveness analysis comparing different transfusion strategies. This will be the largest study to date assessing ROTEM in this setting, overcoming the limitations of previous studies, which have been mostly retrospective with heterogeneous populations and procedures. Its findings could contribute to the standardization of transfusion management in cirrhosis and improve healthcare resource efficiency. The widespread availability of ROTEM in other disciplines within the National Health System will facilitate its implementation in this clinical setting without requiring additional investment in equipment.

Inclusion Criteria:

• Age between 18 and 85 years.
• Clinical, analytical, elastographic, histological, and/or imaging criteria consistent with the diagnosis of hepatic cirrhosis.
• Undergoing a high-risk invasive procedure, either in an outpatient setting or during hospitalization.
• Platelet count below 50,000/μL or INR greater than 1.5 with a platelet count below 100,000/μL.
• Signature of informed consent.

Exclusion Criteria:

• Cirrhotic patients with acute-on-chronic liver failure (ACLF) as defined by EASL criteria, and patients admitted to Intensive Care Units. These patients are excluded because hemostatic alterations in ACLF and critically ill patients are different and more pronounced compared to those in outpatient or general medical ward settings.
• Chronic kidney disease stage ≥3.
• Presence and/or history of thromboembolic complications.
• Presence of non-hepatic tumors.
• Presence of any primary hematologic disease (including inherited coagulopathies or thrombophilia).
• Recent surgery (<8 weeks).
• History of organ transplantation, including liver transplantation.
• Pregnancy.
• Use of anticoagulants, antiplatelet agents other than acetylsalicylic acid, and/or antifibrinolytic therapy.
• Active disseminated intravascular coagulation.

patients with cirrhosis undergoing invasive procedures