Rotational Thromboelastometry (ROTEM™) Guided Transfusion for Elective Procedures in Patients With Cirrhosis (REduCe): An Open Label Randomized Controlled Trial.

Inclusion Criteria: Patients with Cirrhosis undergoing elective procedure must meet all following criterias. 1. Patients undergoing the following elective procedures will be included in the study 1. Gastroscopy with endoscopic variceal ligation 2. Colonoscopy with polypectomy and endoscopic mucosal resection 3. ERCP with sphincterotomy 4. Percutaneous liver biopsy 5. Biopsy of other sites (excluding liver) 6. Hepatic venous pressure gradient with or without liver biopsy 7. Elective Transjugular Intrahepatic Portosystemic Shunt 8. Portal Vein embolization 9. Trans-arterial chemo-embolization (TACE) 10. Thermal ablation of hepatocellular carcinoma 11. Large volume paracentesis 12. Central venous catheter insertion 13. Thoracentesis 2. Age: Older than 21 years 3. Coagulopathy based on conventional coagulation tests which is defined as 1. INR \> 1.5 and/or aPTT \> 1.5x ULN for PTT and/or 2. Platelets \< 50,000/mm3/uL 4. Patients with acute decompensation, acute on chronic liver failure and acute liver failure. 5. Able to give informed consent. Exclusion Criteria: 1. Emergency procedures. (defined as life-saving procedures) 2. On-going bleeding 3. Under 21 years of age 4. Inability to obtain informed consent from patients 5. Coagulation disorders (other than those relating to liver disease) 6. Patients on anticoagulant medications (e.g. warfarin, enoxaparin, rivaroxaban, dabigatran, apixaban, heparin, clexane etc.) 7. Patients on anti-platelet aggregation agents other than aspirin (e.g. clopidogrel, ticagrelor) 8. Active malignancy except hepatocellular carcinoma 9. Patients who have received FFP, platelet transfusion, cryoprecipitate within last 7 days 10. Patients with stage 4 or 5 chronic kidney disease 11. Patients receiving renal replacement therapy 12. Patients with active sepsis as defined by ACPP-SCCM criteria (21). 13. Pregnant Women