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Kumar R, Ng LX, Wong YJ, Tan CK, Wang LZ, Qiu TY, Wong B, Lin KW, Li JW, Kwek AB, Ang TL, Gokhle RS, Sivanath TP. Rotational Thromboelastometry Reduces the Need for Preemptive Transfusion in Cirrhosis: A Randomized Controlled Trial (NCT:05698134). J Clin Exp Hepatol 2025; 15:102409. [PMID: 39391324 PMCID: PMC11462181 DOI: 10.1016/j.jceh.2024.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 09/04/2024] [Indexed: 10/12/2024] Open
Abstract
Backgrounds and aim Viscoelastic tests (VET) like rotational thromboelastometry (ROTEM) assess global hemostasis in cirrhosis. We aimed to assess whether ROTEM-guided blood product transfusion results in lower blood product requirements in patients with cirrhosis undergoing elective invasive procedures as compared to standard of care (SOC) based on conventional coagulation test (CCT). Methods In this open label randomized controlled trial, patients with cirrhosis and abnormal CCT who were undergoing an invasive procedure were randomized to receive blood products either by ROTEM-guidance or SOC. The primary outcome was the difference in blood products (fresh frozen plasma (FFP) or platelets) transfused between the groups. The secondary outcome was procedure-related bleeding or complications within 7 days of the procedure. The trial protocol is registered at clinicaltrails.gov; NCT05698134. Results From August 2021 to January 2023, a total of 40 patients were recruited (ROTEM (n = 20) and SOC (n = 20)). The trial was terminated earlier during interim analyses due to compelling benefit in the ROTEM group after a scheduled interim analysis. The ROTEM group required substantially less blood transfusion than the SOC group (40% [8/20] vs 100% [20/20], P < 0.001). The benefit was consistent across all types of blood product, including fresh frozen plasma (<0.001) and pooled platelets (P = 0.046). No patients experienced clinically significant bleeding events. Transfusion-associated adverse events occurred in one patient (5%) in the SOC group (allergic reaction) and none in the ROTEM group (P = NS). The mortality in both groups at 30 and 90 days was similar. Conclusions Viscoelastic tests like ROTEM provide global assessment of hemostasis in patients with cirrhosis. Institution of ROTEM based transfusion strategy significantly reduces the need for blood product transfusion in patients with cirrhosis undergoing elective procedure without any increased risk of bleeding events. Clinical trial number NCT05698134.
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Affiliation(s)
- Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- DUKE-NUS Academic Medical Centre, Singapore
| | - Louis X.L. Ng
- Department of Anesthesia and Critical Care, Changi General Hospital, Singapore
| | - Yu J. Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- DUKE-NUS Academic Medical Centre, Singapore
| | - Chin K. Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Louis Z. Wang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tian Y. Qiu
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Benny Wong
- Clinical Trials and Research Unit, Changi General Hospital Singapore
| | - Kenneth W. Lin
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James W. Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew B.E. Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing L. Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Roshni S. Gokhle
- Department of Respiratory Medicine and Critical Care, Changi General Hospital, Singapore
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Reardon B, Pasalic L, Favaloro EJ. The Role of Viscoelastic Testing in Assessing Hemostasis: A Challenge to Standard Laboratory Assays? J Clin Med 2024; 13:3612. [PMID: 38930139 PMCID: PMC11205135 DOI: 10.3390/jcm13123612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Viscoelastic testing is increasingly being used in clinical and research settings to assess hemostasis. Indeed, there are potential situations in which viscoelastic testing is reportedly superior to standard routine laboratory testing for hemostasis. We report the current testing platforms and terminology, as well as providing a concise narrative review of the published evidence to guide its use in various clinical settings. Notably, there is increasing evidence of the potential utility of viscoelastic testing for assessment of direct oral anticoagulants, and bleeding associated with chronic liver disease, orthotopic liver transplantation, cardiac surgery, trauma, obstetrics and pediatrics.
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Affiliation(s)
- Benjamin Reardon
- School of Medicine and Public Health, Joint Medical Program, University of Newcastle, Callaghan, NSW 2145, Australia;
- Haematology Department, Calvary Mater Hospital Newcastle, Waratah, NSW 2298, Australia
| | - Leonardo Pasalic
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia;
- Westmead Clinical School, University of Sydney, Westmead, NSW 2145, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Emmanuel J. Favaloro
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia;
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW 2650, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
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Sarmiento IA, Guzmán MF, Chapochnick J, Meier J. Implementation of a Bleeding Management Algorithm in Liver Transplantation: A Pilot Study. Transfus Med Hemother 2024; 51:1-11. [PMID: 38314241 PMCID: PMC10836948 DOI: 10.1159/000530579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/03/2023] [Indexed: 02/06/2024] Open
Abstract
Objectives The aims of the study were to compare the consumption of blood products before and after the implementation of a bleeding management algorithm in patients undergoing liver transplantation and to determine the feasibility of a multicentre, randomized study. Background Liver transplantation remains the only curative therapy for patients with end-stage liver disease, but it carries a high risk of surgical bleeding. Materials and Methods Retrospective study of patients treated before (group 1) and after (group 2) implementation of a haemostatic algorithm guided by viscoelastic testing, including use of lyophilized coagulation factor concentrates (prothrombin complex and fibrinogen concentrates). Primary outcome was the number of units of blood products transfused in 24 h after surgery. Secondary outcomes included hospital stay, mortality, and cost. Results Data from 30 consecutive patients was analysed; 14 in group 1 and 16 in group 2. Baseline data were similar between groups. Median total blood product consumption 24 h after surgery was 33 U (IQR: 11-57) in group 1 and 1.5 (0-23.5) in group 2 (p = 0.028). Significantly fewer units of red blood cells, fresh frozen plasma, and cryoprecipitate were transfused in group 2 versus group 1. There was no significant difference in complications, hospital stay, or in-hospital mortality between groups. The cost of haemostatic therapy was non-significantly lower in group 2 versus group 1 (7,400 vs. 15,500 USD; p = 0.454). Conclusion The haemostatic management algorithm was associated with a significant reduction in blood product use during 24 h after liver transplantation. This study demonstrated the feasibility and provided a sample size calculation for a larger, randomized study.
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Affiliation(s)
| | - María F Guzmán
- Department of Anesthesiology, Universidad de los Andes, Santiago de Chile, Chile
| | | | - Jens Meier
- Department for Anesthesiology and Critical Care, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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Soucy-Proulx M, Kato H, Coeckelenbergh S, Naili Kortaia S, Herboulier L, Pittau G, Pham P, Lemoine A, Duranteau J, Roullet S. Sonorheometry Device Thresholds in Liver Transplantation: An Observational Retrospective Study. J Clin Med 2024; 13:696. [PMID: 38337389 PMCID: PMC10856129 DOI: 10.3390/jcm13030696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) remains a potentially haemorrhagic procedure whose perioperative bleeding and transfusion could be better monitored using point-of-care devices. Quantra® is a device based on sonorheometry to assess whole blood clot formation. Our aims were to describe Quantra® parameters during LT and to study their correlations with standard laboratory parameters, and to determine Quantra® cut-off values for thrombocytopenia, hypofibrinogenemia and coagulation factors' deficit. METHODS In 34 patients undergoing LT, blood samples were collected before surgical incision, 15 min after the beginning of the anhepatic phase, and 15 min after arterial revascularization of the graft. RESULTS Clotting time (CT) was well correlated with prothrombin (PT) ratio and activated partial thromboplastin time (aPTT) ratio. Platelet contribution to clot stiffness (PCS) was correlated with platelets (ρ = 0.82, p < 0.001) and fibrinogen contribution clot stiffness (FCS) with fibrinogen (Fg) (ρ = 0.74, p < 0.001). CT predicted a PT ratio < 30% with an area under the curve (AUC) of 0.93 (95% CI 0.87-0.98; p < 0.001). PCS predicted a platelet count < 50 G/L with an AUC of 0.87 (95% CI 0.76-0.98, p < 0.001). FCS predicted a Fg < 1.0, 1.2 or 1.5 g/L, with an AUC of 0.86 (95% CI 0.77-094, p < 0.001), 0.82 (95% CI 0.74-0.91, p < 0.001) and 0.88 (95% CI 0.82-0.95, p < 0.001), respectively. CONCLUSION Quantra® provides a rapid assessment of haemostasis during LT.
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Affiliation(s)
- Maxim Soucy-Proulx
- Service d’Anesthésie-Réanimation, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (M.S.-P.); (H.K.); (S.C.); (S.N.K.); (L.H.)
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Montreal, QC H2X 0A9, Canada
| | - Hiromi Kato
- Service d’Anesthésie-Réanimation, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (M.S.-P.); (H.K.); (S.C.); (S.N.K.); (L.H.)
| | - Sean Coeckelenbergh
- Service d’Anesthésie-Réanimation, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (M.S.-P.); (H.K.); (S.C.); (S.N.K.); (L.H.)
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Salima Naili Kortaia
- Service d’Anesthésie-Réanimation, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (M.S.-P.); (H.K.); (S.C.); (S.N.K.); (L.H.)
| | - Laurence Herboulier
- Service d’Anesthésie-Réanimation, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (M.S.-P.); (H.K.); (S.C.); (S.N.K.); (L.H.)
| | - Gabriella Pittau
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France;
| | - Patrick Pham
- Service de Biochimie et Oncogénétique, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (P.P.); (A.L.)
| | - Antoinette Lemoine
- Service de Biochimie et Oncogénétique, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (P.P.); (A.L.)
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94276 Le Kremlin-Bicêtre, France;
| | - Stéphanie Roullet
- Service d’Anesthésie-Réanimation, Hôpital Paul Brousse, Assistance Publique—Hôpitaux de Paris (AP-HP), Université Paris Saclay, 94800 Villejuif, France; (M.S.-P.); (H.K.); (S.C.); (S.N.K.); (L.H.)
- INSERM, Hémostase Inflammation Thrombose HITH U1176, Université Paris Saclay, 94276 Le Kremlin-Bicêtre, France
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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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Kataria S, Juneja D, Singh O. Approach to thromboelastography-based transfusion in cirrhosis: An alternative perspective on coagulation disorders. World J Gastroenterol 2023; 29:1460-1474. [PMID: 36998429 PMCID: PMC10044856 DOI: 10.3748/wjg.v29.i9.1460] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023] Open
Abstract
Viscoelastic tests, specifically thromboelastography and rotational thromboelastometry, are increasingly being used in the management of postoperative bleeding in surgical intensive care units (ICUs). However, life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs, especially those with underlying liver dysfunction. Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications. Compared to conventional coagulation tests, a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices, which may aid physicians in making a rapid diagnosis and instituting early interventions. These tests may help predict bleeding and rationalize the use of blood products in these patients.
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Affiliation(s)
- Sahil Kataria
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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7
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Stewart E, Nydam TL, Hendrickse A, Pomposelli JJ, Pomfret EA, Moore HB. Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation. Semin Thromb Hemost 2023; 49:119-133. [PMID: 36318962 PMCID: PMC10366939 DOI: 10.1055/s-0042-1758058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.
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Affiliation(s)
- Erin Stewart
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Adrian Hendrickse
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - James J. Pomposelli
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Bareille M, Lecompte T, Mullier F, Roullet S. Are Viscoelastometric Assays of Old Generation Ready for Disposal? Comment on Volod et al. Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J. Clin. Med. 2022, 11, 860. J Clin Med 2023; 12:jcm12020477. [PMID: 36675406 PMCID: PMC9866463 DOI: 10.3390/jcm12020477] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/17/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
With the advent of new viscoelastometric hemostatic assay (VHA) devices, with ready-to-use cartridge reagents allowing for their use by people without special laboratory skills, the appreciation of the actual clinical value of VHAs in settings such as severe trauma, post-partum hemorrhage, cardiac surgery and liver transplantation still needs to be fully validated. While two of the newest versions remain based on a 'cup and pin' system (ROTEM® sigma, ClotPro®), two other new devices (TEG® 6s, Quantra®) rely on very different technologies: clotting blood is no longer in contact with the probe and challenged by oscillation of one of the components but explored with ultrasound exposure. A systematic literature search (including Sonoclot®) retrieved 20 observational studies (19 prospective). Most studies pointed to imperfect agreements, highlighting the non-interchangeability of devices. Only a few studies, often with a limited number of patients enrolled, used a clinical outcome. No study compared VHA results with conventional laboratory assays obtained through a rapid tests panel. Clinical evidence of the utility of the new VHAs largely remains to be proven through randomized clinical trials, with clinically relevant outcomes, and compared to rapid panel hemostasis testing. The availability of new, improved VHA devices provides an impetus and an opportunity to do so.
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Affiliation(s)
- Marion Bareille
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, 5530 Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, 5000 Namur, Belgium
- Université de Lorraine, 54000 Nancy, France
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, 5530 Yvoir, Belgium
- Correspondence:
| | - Stéphanie Roullet
- Laboratory for Hemostasis, Inflammation & Thrombosis (HITh), Unité Mixte de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
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Viscoelastic versus conventional coagulation tests to reduce blood product transfusion in patients undergoing liver transplantation: A systematic review and meta-analysis. Eur J Anaesthesiol 2023; 40:39-53. [PMID: 36412263 DOI: 10.1097/eja.0000000000001780] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recent literature suggests viscoelastic test (VET)-guided transfusion management could be associated with reduced blood product administration in patients undergoing liver transplantation. OBJECTIVES To assess the effectiveness of coagulation management guided by VETs compared with conventional coagulation tests (CCTs) in reducing blood product transfusion in patients undergoing liver transplantation. DESIGN Systematic review and meta-analysis of randomised (RCTs) and nonrandomised clinical trials performed according to PRISMA guidelines. The protocol was previously published (PROSPERO: CRD42021230213). DATA SOURCES The Cochrane Central Library, PubMed/MEDLINE, Embase and the Transfusion Evidence Library were searched up to 30 th January 2022. ELIGIBILITY CRITERIA Setting: operating room. Patients: liver transplantation recipients. Intervention: use of VETs versus CCTs. Main outcome measures: the primary outcome was the mean number of transfused units for each blood product including red blood cells (RBCs), fresh frozen plasma (FFP), platelets (PLTs) and cryoprecipitate. Secondary outcomes included mortality rate, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Seventeen studies ( n = 5345 patients), 15 observational and two RCTs, were included in this review. There was a mean difference reduction in RBCs [mean difference: -1.40, 95% confidence interval (95% CI), -1.87 to -0.92; P < 0.001, I2 = 61%) and FFP units (mean difference: -2.98, 95% CI, -4.61 to -1.35; P = < 0.001; I2 = 98%) transfused in the VETs group compared with the CCTs one. A greater amount of cryoprecipitate was administered in the VETs group (mean difference: 2.71, 95% CI, 0.84 to 4.58; P = 0.005; I2 = 91%). There was no significant difference in the mean number of PLT units, mortality, hospital and ICU-LOS. CONCLUSION Our meta-analysis demonstrated that VETs implementation was associated with reduced RBC and FFP consumption in liver transplantation patients without effects on mortality and hospital and ICU-LOS. The certainty of evidence ranged from moderate to very low. Further well conducted RCTs are needed to improve the certainty of evidence.
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Yoon U, Bartoszko J, Bezinover D, Biancofiore G, Forkin KT, Rahman S, Spiro M, Raptis DA, Kang Y. Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short-term outcomes after liver transplantation-A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14637. [PMID: 35249250 DOI: 10.1111/ctr.14637] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease (ESLD), that is, often multifactorial. OBJECTIVES The objective of this systematic review was to identify evidence based intraoperative transfusion and coagulation management strategies that improve immediate and short-term outcomes after LT. METHODS PRISMA-guidelines and GRADE-approach were followed. Three subquestions were formulated. (Q); Q1: transfusion management; Q2: antifibrinolytic therapy; and Q3: coagulation monitoring. RESULTS Sixteen studies were included for Q1, six for Q2, and 10 for Q3. Q1: PRBC and platelet transfusions were associated with higher mortality. The use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) were not associated with reductions in intraoperative transfusion or increased thrombotic events. The use of cell salvage was not associated with hepatocellular carcinoma (HCC) recurrence or mortality. Cell salvage and transfusion education significantly decreased blood product transfusions. Q2: Epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA) were not associated with decreased blood product transfusion, improvements in patient or graft survival, or increases in thrombotic events. Q3: Viscoelastic testing (VET) was associated with decreased allogeneic blood product transfusion compared to conventional coagulation tests (CCT) and is likely to be cost-effective. Coagulation management guided by VET may be associated with increases in FC and PCC use. CONCLUSION Q1: A specific blood product transfusion practice is not recommended (QOE; low | Recommendation; weak). Cell salvage and educational interventions are recommended (QOE: low | Grade of Recommendation: moderate). Q2: The routine use of antifibrinolytics is not recommended (QOE; low | Recommendation; weak). Q3: The use of VET is recommended (QOE; low-moderate | Recommendation; strong).
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania, USA
| | | | - Katherine T Forkin
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Suehana Rahman
- Department of Anaesthesiology, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Yoogoo Kang
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Pillai AA, Kriss M, Al‐Adra DP, Chadha RM, Cushing MM, Farsad K, Fortune BE, Hess AS, Lewandowski R, Nadim MK, Nydam T, Sharma P, Karvellas CJ, Intagliata N. Coagulopathy and hemostasis management in patients undergoing liver transplantation: Defining a dynamic spectrum across phases of care. Liver Transpl 2022; 28:1651-1663. [PMID: 35253365 PMCID: PMC9790275 DOI: 10.1002/lt.26451] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/10/2023]
Abstract
Patients with acute and chronic liver disease present with a wide range of disease states and severity that may require liver transplantation (LT). Physiologic alterations occur that are dynamic throughout all phases of perioperative care, creating complex management scenarios that necessitate multidisciplinary clinical care. Specifically, alterations in hemostasis in liver disease can be pronounced and evolve with disease progression over time. Recent studies and society guidance address this emerging paradigm and offer recommendations to assist with hemostatic management in patients with liver disease. However, patients undergoing LT are unique and diverse, often with unstable disease that requires specialized approaches. Our aim is to provide a focused review of hemostatic management of the LT patient, distinguish unique aspects of the three main phases of care (before LT, perioperative, and after LT), and identify knowledge gaps and critical areas of future research.
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Affiliation(s)
- Anjana A. Pillai
- Department of MedicineUniversity of Chicago MedicineChicagoIllinoisUSA
| | - Michael Kriss
- Department of Internal MedicineUniversity of ColoradoAuroraColoradoUSA
| | - David P. Al‐Adra
- Department of SurgerySchool of Medicine and Public HealthUniversity of WisconsinMadisonWisconsinUSA
| | - Ryan M. Chadha
- Department of Anesthesiology and Perioperative MedicineMayo ClinicJacksonvilleFloridaUSA
| | - Melissa M. Cushing
- Department of Pathology and Laboratory MedicineWeill Cornell MedicineNew YorkNew YorkUSA
| | - Khashayar Farsad
- Department of Interventional RadiologyOregon Health & Science UniversityPortlandOregonUSA
| | | | - Aaron S. Hess
- Department of AnesthesiologyUniversity of WisconsinMadisonWisconsinUSA,Department of Pathology & Laboratory MedicineUniversity of WisconsinMadisonWisconsinUSA
| | | | - Mitra K. Nadim
- Department of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Trevor Nydam
- Department of SurgeryUniversity of ColoradoAuroraColoradoUSA
| | - Pratima Sharma
- Department of MedicineUniversity of MichiganAnn ArborMichiganUSA
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12
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Kirchner VA, O'Farrell B, Imber C, McCormack L, Northup PG, Song GW, Spiro M, Raptis DA, Durand F. What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery, or portal vein thrombosis? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14629. [PMID: 35240723 PMCID: PMC10078564 DOI: 10.1111/ctr.14629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/13/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288). RESULTS Of the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding. CONCLUSIONS Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.
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Affiliation(s)
- Varvara A Kirchner
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, USA.,Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, USA
| | | | - Charles Imber
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Lucas McCormack
- Liver Surgery and Transplantation Unit, Department of Surgery, Hospital Aleman, Buenos Aires, Argentina
| | - Patrick G Northup
- Division of Gastroenterology, Department of Medicine, University of Virginia Health System, Charlottesville, USA
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - François Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France.,University of Paris, Paris, France.,INSER M U1149, Paris, France
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- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, USA
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13
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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14
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Roullet S, Rivoire T, Houssin C, Labrouche S, Paquin S, Nouette-Gaulain K, Deneux-Tharaux C, Amiral J, James C, Sentilhes L. Hemostatic Effects of Tranexamic Acid in Cesarean Delivery: An Ancillary Study of the TRAAP2 Study. Thromb Haemost 2022; 122:1869-1878. [PMID: 36075235 DOI: 10.1055/s-0042-1755379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Fibrinolysis activation during delivery contributes to postpartum hemorrhage (PPH). Clot lysis time studied with the global fibrinolytic capacity device (GFC/LT) is a functional test which rapidly assesses fibrinolytic profile. Tranexamic acid (TXA) is an efficient antifibrinolytic therapy. METHODS We prospectively studied fibrinolysis and coagulation in 33 women included in the TRAAP2 trial, which aimed to assess the impact of TXA in preventing PPH following a cesarean delivery. TXA or placebo was randomly administered after childbirth as part of the TRAAP2 trial's protocol. Fibrinolytic (GFC/LT, plasma concentration of fibrinolysis activators and inhibitors) and hemostatic parameters were assayed at three sample times (TREF [T-reference] after anesthesia, T15 and T120minutes after TXA, or placebo administration). RESULTS All cesarean deliveries were elective. In the placebo group, the clot lysis time assessed with GFC/LT significantly decreased between TREF and T120, indicating an activated fibrinolysis (44 [interquartile range, IQR: 40-48] vs. 34 [IQR: 30-36] minutes, p<0.001). In both TXA and placebo groups, significant fluctuations of the plasmatic concentrations of fibrinolytic mediators were noticed over time, suggesting fibrinolysis activation. Clot lysis time measured by GFC/LT was significantly increased in women of the TXA group as compared with those in the placebo group at T15 (120 [120-120] vs. 36 [34-41] minutes, p<0.001) and T120minutes (113 [99-120] vs. 34 [30-36] minutes, p<0.001) after drug administration, indicating a decreased in fibrinolysis in those women. CONCLUSIONS GFC/LT evidenced fibrinolysis activation during cesarean delivery, linked to a decrease in fibrinolytic inhibitors. GFC/LT revealed a significant antifibrinolytic effect of TXA compared with placebo.
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Affiliation(s)
- Stéphanie Roullet
- Pôle d'Anesthésie-Réanimation, CHU Bordeaux, Bordeaux, France.,INSERM, Biologie des Maladies Cardiovasculaires, University of Bordeaux, U1034, Pessac, France
| | | | - Clémence Houssin
- Département de Gynécologie et Obstétrique, CHU Bordeaux, Bordeaux, France
| | - Sylvie Labrouche
- INSERM, Biologie des Maladies Cardiovasculaires, University of Bordeaux, U1034, Pessac, France.,Laboratoire d'hématologie, CHU Bordeaux, Bordeaux, France
| | - Sandrine Paquin
- Pôle d'Anesthésie-Réanimation, CHU Bordeaux, Bordeaux, France
| | - Karine Nouette-Gaulain
- Pôle d'Anesthésie-Réanimation, CHU Bordeaux, Bordeaux, France.,INSERM, Maladies Rares: Génétique et Métabolisme, University of Bordeaux, Bordeaux, France
| | - Catherine Deneux-Tharaux
- INSERM, Perinatal Obstetrical and Pediatric Epidemiology Research Team (EPOPé), Centre for Research on Epidemiology and Statistics (CRESS), Paris University, Paris, France
| | | | - Chloé James
- INSERM, Biologie des Maladies Cardiovasculaires, University of Bordeaux, U1034, Pessac, France.,Laboratoire d'hématologie, CHU Bordeaux, Bordeaux, France
| | - Loïc Sentilhes
- Département de Gynécologie et Obstétrique, CHU Bordeaux, Bordeaux, France
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15
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Malleeswaran S, Sivajothi S, Reddy MS. Viscoelastic Monitoring in Liver Transplantation. Liver Transpl 2022; 28:1090-1102. [PMID: 34724319 DOI: 10.1002/lt.26352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022]
Abstract
Cirrhosis and liver transplantation (LT) surgery are associated with substantial alterations to the patient's coagulation status. Accurate monitoring of these changes during LT can help manage bleeding proactively and potentially reduce transfusion requirements. Unlike conventional coagulation tests (CCTs), viscoelastic monitoring (VEM) can provide an accurate, real-time, point-of-care assessment of coagulation status during LT and hence has become an invaluable tool for anesthetists and intensive care physicians. However, it remains an enigmatic subject for transplantation surgeons who are more conversant with CCTs. This review discusses the principles of VEM, provides a primer to understanding and interpreting its output, and explains how it can be used to make real-world clinical decisions during LT.
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Affiliation(s)
- Selvakumar Malleeswaran
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Sivanesan Sivajothi
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Mettu Srinivas Reddy
- Department of Hepatobiliary Surgery and Liver Transplantation, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
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16
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Shettar SS, Vandyck K, Tanaka KA. Coagulation Management in End-Stage Liver Disease. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Lee JM, Hong K, Han ES, Suh S, Hong S, Hong SK, Choi Y, Yi NJ, Lee KW, Suh KS. LigaSure versus monopolar cautery for recipient hepatectomy in liver transplantation: a propensity score-matched analysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1050. [PMID: 34422962 PMCID: PMC8339826 DOI: 10.21037/atm-21-1318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/20/2021] [Indexed: 11/06/2022]
Abstract
Background Recipient hepatectomy during liver transplantation (LT) is one of the most challenging aspects of surgery due to the possibility of massive bleeding. This study aimed to compare and analyze the effectiveness between LigaSure and monopolar cautery in recipients. Methods We reviewed 187 recipients who underwent LT from March 2019 to June 2020. We compared the surgical outcomes of the 69 recipients who underwent recipient hepatectomy with LigaSure (LigaSure group) and 118 recipients who underwent with monopolar cautery. Propensity score matching (PSM) was performed using the nearest-neighbor method at a ratio of 1:1 based on 14 baseline characteristics and possible factors that influence postoperative bleeding. Results A total of 187 adult recipients were reviewed retrospectively. In the propensity score-matched analysis, The rates of bleeding and infectious complication were significantly lower in the LigaSure group than in the monopolar cautery group (3/69, 4.35% versus 13/69, 18.8%; P=0.015 and 1/69, 1.45% versus 9/69, 13.0%; P=0.017). The length of postoperative hospital stay was shorter in the LigaSure group (mean: 23.1±16.1 versus 39.6±58.2 days; P=0.024). Conclusions Recipient hepatectomy with LigaSure is associated with a short hospital stay due to low re-operation rates, postoperative bleeding, and secondary infection related to bleeding.
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Affiliation(s)
- Jeong-Moo Lee
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Kwangpyo Hong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Eui Soo Han
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sanggyun Suh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Suyoung Hong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
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18
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Justo I, Marcacuzco A, Caso O, García-Conde M, Manrique A, Calvo J, García-Sesma A, Cambra F, García A, Cortés M, Loinaz C, Jiménez-Romero C. Hemoderivative Transfusion in Liver Transplantation: Comparison Between Recipients of Grafts From Brain Death Donors and Recipients of Uncontrolled Donors After Circulatory Death. Transplant Proc 2021; 53:2298-2304. [PMID: 34419255 DOI: 10.1016/j.transproceed.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/07/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival. MATERIALS AND METHODS Between January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients. RESULTS No difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070). CONCLUSION The use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.
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Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain.
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Oscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Félix Cambra
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Adolfo García
- Department of Anesthesiology, Perioperative and Pain Medicine, "Doce de Octubre" University Hospital, Madrid, Spain
| | - Manuel Cortés
- Department of Anesthesiology, Perioperative and Pain Medicine, "Doce de Octubre" University Hospital, Madrid, Spain
| | - Carmelo Loinaz
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
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19
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Cohen T, Haas T, Cushing MM. The strengths and weaknesses of viscoelastic testing compared to traditional coagulation testing. Transfusion 2021; 60 Suppl 6:S21-S28. [PMID: 33089934 DOI: 10.1111/trf.16073] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 06/05/2020] [Indexed: 12/25/2022]
Abstract
Optimized acute bleeding management requires timely and reliable laboratory testing to detect and diagnose coagulopathies and guide transfusion therapy. Conventional coagulation tests (CCT) are inexpensive with minimal labor requirements, but CCTs may have delayed turnaround times. In addition, abnormal CCT values may not reflect in vivo coagulopathies that require treatment and may lead to overtransfusion. The use of viscoelastic testing (VET) has been rapidly expanding and is recommended by several recent bleeding guidelines. This review is intended to compare CCT to VET, review the strengths and weaknesses of both approaches, and evaluate and summarize the clinical studies that compared CCT-based and VET-based transfusion algorithms. Most studies of CCT vs VET transfusion algorithms favor the use of VET in the management of massively bleeding patients due to reductions in blood product utilization, bleeding, costs, and lengths of stay.
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Affiliation(s)
- Tobias Cohen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Transfusion Medicine, NewYork-Presbyterian Hospital-Weill Cornell, New York, New York, USA
| | - Thorsten Haas
- Department of Anesthesiology, University Children's Hospital, Zurich, Switzerland
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Transfusion Medicine, NewYork-Presbyterian Hospital-Weill Cornell, New York, New York, USA
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20
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Major Thromboembolic Complications in Liver Transplantation: The Role of Rotational Thromboelastometry and Cryoprecipitate Transfusion. Transplantation 2021; 105:1771-1777. [PMID: 32852404 DOI: 10.1097/tp.0000000000003427] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although hemorrhage is a major concern during liver transplantation (LT), the risk for thromboembolism is well recognized. Implementation of rotational thromboelastometry (ROTEM) has been associated with the increased use of cryoprecipitate; however, the role of ROTEM-guided transfusion strategy and cryoprecipitate administration in the development of major thromboembolic complications (MTCs) has never been documented. METHODS We conducted a study on patients undergoing LT before and after the implementation of ROTEM. We defined MTC as intracardiac thrombus, pulmonary embolism, hepatic artery thrombosis, and ischemic stroke in 30 d after LT. We used a propensity score to match patients during the 2 study periods. RESULTS Among 2330 patients, 119 (4.9%) developed MTC. The implementation of ROTEM was significantly associated with an increase in cryoprecipitate use (1.1 ± 1.1 versus 2.9 ± 2.3 units, P < 0.001) and MTC (4.2% versus 9.5%, P < 0.001). Further analysis demonstrated that the use of cryoprecipitate was an independent risk factor for MTC (odds ratio 1.1, 95% confidence interval 1.04-1.24, P = 0.003). Patients with MTC had significantly lower 1-y survival. CONCLUSIONS Our study suggests that the implementation of ROTEM and the use of cryoprecipitate play significant roles in the development of MTC in LT. The benefits and risks of cryoprecipitate transfusion should be carefully evaluated before administration.
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21
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Response to Letter-to-the-Editor. Transplantation 2021; 105:e60. [PMID: 33901132 DOI: 10.1097/tp.0000000000003657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Khan J, Dunbar NM. Time to stop worrying about ABO incompatible cryoprecipitate transfusions in adults. Transfusion 2021; 61:1-4. [PMID: 33616962 DOI: 10.1111/trf.16228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Jenna Khan
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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23
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Yoo SY, Kim GS. Changes in the allocation policy for deceased donor livers in Korea: perspectives from anesthesiologists. Anesth Pain Med (Seoul) 2021; 16:68-74. [PMID: 33486941 PMCID: PMC7861900 DOI: 10.17085/apm.20035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022] Open
Abstract
Background The allocation policy for deceased donor livers in Korea was changed in June 2016 from Child-Turcotte-Pugh (CTP) scoring system-based to Model for End-stage Liver Disease (MELD) scoring system-based. Thus, it is necessary to review the effect of allocation policy changes on anesthetic management. Methods Medical records of deceased donor liver transplantation (DDLT) from December 2014 to May 2017 were reviewed. We compared the perioperative parameters before and after the change in allocation policy. Results Thirty-seven patients underwent DDLT from December 2014 to May 2016 (CTP group), and 42 patients underwent DDLT from June 2016 to May 2017 (MELD group). The MELD score was significantly higher in the MELD group than in the CTP group (36.5 ± 4.6 vs. 26.5 ± 9.4, P < 0.001). The incidence of hepatorenal syndrome was higher in the MELD group than in the CTP group (26 vs. 7, P < 0.001). Packed red blood cell transfusion occurred more frequently in the MELD group than in the CTP group (5.0 ± 3.6 units vs. 3.4 ± 2.2 units, P = 0.025). However, intraoperative bleeding, vasopressor support, and postoperative outcomes were not different between the two groups. Conclusions Even though the patient’s objective condition deteriorated, perioperative parameters did not change significantly.
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Affiliation(s)
- Seung Yeon Yoo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gaspari R, Teofili L, Aceto P, Valentini CG, Punzo G, Sollazzi L, Agnes S, Avolio AW. Thromboelastography does not reduce transfusion requirements in liver transplantation: A propensity score-matched study. J Clin Anesth 2020; 69:110154. [PMID: 33333373 DOI: 10.1016/j.jclinane.2020.110154] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/05/2020] [Accepted: 11/21/2020] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVE To compare total blood product requirements in liver transplantation (LT) assisted by thromboelastography (TEG) or conventional coagulation tests (CCTs). DESIGN Retrospective observational study. SETTING A tertiary care referral center for LT. PATIENTS Adult patients undergoing LT from deceased donor. INTERVENTION Hemostasis was monitored by TEG or CCTs and corresponding transfusion algorithms were adopted. MEASUREMENTS Number and types of blood products (red blood cells, RBC; fresh-frozen plasma, FFP; platelets, PLT) transfused from the beginning of surgery until the admission to the intensive care unit. METHODS We compared data retrospectively collected in 226 LTs, grouped according to the type of hemostasis monitoring (90 with TEG and 136 with CCTs, respectively). Confounding variables affecting transfusion needs (recipient age, sex, previous hepatocellular carcinoma surgery, Model for End Stage Liver Disease - MELD, baseline hemoglobin, fibrinogen, creatinine, veno-venous by pass, and trans-jugular intrahepatic portosystemic shunt) were managed by propensity score match (PSM). MAIN RESULTS The preliminary analysis showed that patients in the TEG group received fewer total blood products (RBC + FFP + PLT; p = 0.001, FFP (p = 0.001), and RBC (p = 0.001). After PSM, 89 CCT patients were selected and matched to the 90 TEG patients. CCT and TEG matched patients received similar amount of total blood products. In a subgroup of 39 patients in the top MELD quartile (MELD ≥25), the TEG use resulted in lower consumption of FFP units and total blood products. Nevertheless, due to the low number of patients, any meaningful conclusion could be achieved in this subgroup. CONCLUSIONS In our experience, TEG-guided transfusion in LT does not reduce the intraoperative blood product consumption. Further studies are warranted to assess an advantage for TEG in either the entire LT population or the high-MELD subgroup of patients.
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Affiliation(s)
- Rita Gaspari
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Paola Aceto
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Caterina G Valentini
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giovanni Punzo
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Salvatore Agnes
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alfonso W Avolio
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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Analysis of the hemostatic therapy in liver transplantation guided by rotational thromboelastometry or conventional laboratory tests. Eur J Gastroenterol Hepatol 2020; 32:1452-1457. [PMID: 32118854 DOI: 10.1097/meg.0000000000001660] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coagulopathy is quite common in chronic liver disease patients undergoing orthotopic liver transplantation (OLT). Diagnosis of intraoperative bleeding disorders is based on conventional laboratory tests (CLTs), and thus, the patients are frequently exposed to unnecessary transfusions of blood products. The present study aimed to analyze the intraoperative administration of blood products in patients undergoing OLT, using rotational thromboelastometry (ROTEM) or CLTs. PATIENTS AND METHODS A cohort comprising 153 patients undergoing OLT, of whom 82 were evaluated with ROTEM and 71 by CLTs. Both groups were analyzed intraoperatively: the transfusion of blood products. RESULTS The incidence of patients transfused with cryoprecipitate (CRYO) and/or fibrinogen concentrate (54.9 vs. 19.7%; P < 0.001) and prothrombin complex concentrate (PCC) (32.9 vs. 9.9%; P = 0.008) increased significantly in the ROTEM group than in CLT group, respectively. The amount of transfused patient with CRYO (7.6 vs. 1.2; P < 0.001), fibrinogen concentrate (0.8 vs. 0.2; P = 0.004) and PCC (1.4 vs. 0.2; P = 0.002) increased significantly in the ROTEM group than in the CLT group, respectively. In the analysis of fresh-frozen plasma (FFP), the incidence of transfused patients was significantly higher in the CLT group than in the ROTEM group (46.5 vs. 30.5%; P = 0.047, respectively), with a moderate correlation with red blood cells transfusion (r = 0.67, P < 0.001). The incidence of patients receiving antifibrinolytics was significantly higher in the CLT group than in the ROTEM group (85.9 vs. 47.6%; P < 0.001, respectively). CONCLUSION Transfusion protocol-based thromboelastometry was able to guide administration of hemostatic factors and reduced administration of FFP and antifibrinolytics.
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Thromboelastometry-based algorithms and the need for transfusion during liver transplantation. Eur J Anaesthesiol 2020; 37:518-519. [PMID: 32379157 DOI: 10.1097/eja.0000000000001183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park SY. Viscoelastic coagulation test for liver transplantation. Anesth Pain Med (Seoul) 2020; 15:143-151. [PMID: 33329806 PMCID: PMC7713821 DOI: 10.17085/apm.2020.15.2.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 01/09/2023] Open
Abstract
Coagulation and transfusion management in patients undergoing liver transplantation is challenging. Proper perioperative monitoring of hemostasis is essential to predict the risk of bleeding during surgery, to detect potential causes of hemorrhage in time, and to guide hemostatic therapy. The value of conventional coagulation test is questionable in the acute perioperative setting due to their long turnaround time and the inability to adequately reflect the complex changes in hemostasis in patients with liver disease. Viscoelastic coagulation tests provide simultaneous measurement of multiple aspects of whole-blood coagulation including plasmatic coagulation and fibrinolytic factors and inhibitors that reflect most aspects of hemostasis. Coagulation initiation, mechanical clot stability, and fibrinolysis can be estimated immediately using point-of-care techniques. Therefore, viscoelastic coagulation tests including ROTEM & TEG would be useful to guide patient blood management strategy during liver transplantation.
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Affiliation(s)
- Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Buell TJ, Taylor DG, Chen CJ, Dunn LK, Mullin JP, Mazur MD, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS, Naik BI. Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus 2020; 46:E17. [PMID: 30933918 DOI: 10.3171/2019.1.focus18572] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (β = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.
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Affiliation(s)
| | | | | | - Lauren K Dunn
- 2Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Jeffrey P Mullin
- 3Department of Neurosurgery, University of Buffalo, New York; and
| | - Marcus D Mazur
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | | | | | | | - Bhiken I Naik
- Departments of1Neurosurgery and.,2Anesthesiology, University of Virginia, Charlottesville, Virginia
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Kovalic AJ, Khan MA, Malaver D, Whitson MJ, Teperman LW, Bernstein DE, Singal A, Satapathy SK. Thromboelastography versus standard coagulation testing in the assessment and reversal of coagulopathy among cirrhotics: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2020; 32:291-302. [PMID: 32012141 DOI: 10.1097/meg.0000000000001588] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The utility of thromboelastography/thromboelastometry currently has unvalidated clinical benefit in the assessment and reversal of coagulopathy among cirrhotic patients as compared to standard coagulation testing. A novel systematic review and meta-analysis was conducted in order to assess pooled outcome data among patients receiving thromboelastography/thromboelastometry as compared to standard coagulation testing. As compared to standard coagulation testing, there was a significant reduction in the number of patients requiring pRBC, platelet, and fresh frozen plasma transfusions among thromboelastography/thromboelastometry group with pooled OR 0.53 (95% CI 0.32-0.85; P = 0.009), 0.29 (95% CI 0.12-0.74; P = 0.009), and 0.19 (95% CI 0.12-0.31; P < 0.00001), respectively. Similarly, there was a significant reduction in number of pRBC, platelet, and fresh frozen plasma units transfused in the thromboelastography/thromboelastometry group with pooled MD -1.53 (95% CI -2.86 to -0.21; P = 0.02), -0.57 (95% CI -1.06 to -0.09; P = 0.02), and -2.71 (95% CI -4.34 to -1.07; P = 0.001), respectively. There were significantly decreased total bleeding events with pooled OR 0.54 (95% CI 0.31-0.94; P = 0.03) and amount of intraoperative bleeding during liver transplantation with pooled MD -1.46 (95% CI -2.49 to -0.44; P = 0.005) in the thromboelastography/thromboelastometry group. Overall, there was no significant difference in mortality between groups with pooled OR 0.91 (95% CI 0.63-1.30; P = 0.60). As compared to standard coagulation testing, a thromboelastography/thromboelastometry-guided approach to the assessment and reversal of cirrhotic coagulopathy improves overall number of patients exposed to blood product transfusions, quantity of transfusions, and bleeding events.
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Affiliation(s)
- Alexander J Kovalic
- Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Muhammad Ali Khan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Diego Malaver
- Department of Internal Medicine, Section of Cardiology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Matthew J Whitson
- Department of Internal Medicine, Division of Gastroenterology, Barbara and Zucker School of Medicine for Hofstra/Northwell Health
| | - Lewis W Teperman
- Department of Internal Medicine, Division of Transplantation, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Barbara and Zucker School of Medicine for Hofstra/Northwell Health
| | - David E Bernstein
- Department of Internal Medicine, Division of Transplantation, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Barbara and Zucker School of Medicine for Hofstra/Northwell Health.,Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Barbara and Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York
| | - Ashwani Singal
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of South Dakota Sanford School of Medicine and Avera Transplant Institute, Division of Hepatology, Sioux Falls, South Dakota, USA
| | - Sanjaya K Satapathy
- Department of Internal Medicine, Division of Transplantation, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Barbara and Zucker School of Medicine for Hofstra/Northwell Health.,Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Barbara and Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York
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Lange NW, Salerno DM, Berger K, Cushing MM, Brown RS. Management of Hepatic Coagulopathy in Bleeding and Nonbleeding Patients: An Evidence-Based Review. J Intensive Care Med 2020; 36:524-541. [PMID: 32079443 DOI: 10.1177/0885066620903027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with varying degrees of hepatic dysfunction often present with presumed bleeding diathesis based on interpretation of routine measures of coagulation (prothrombin time [PT], international normalized ratio [INR], and activated partial thromboplastin time). However, standard markers of coagulation do not reflect the actual bleeding risk in this population and may lead to inappropriate administration of hemostatic agents and blood products. The concept of "rebalanced hemostasis" explains both the risk of bleeding and clotting seen in patients with liver dysfunction. The role of pharmacologic agents and blood products for prevention of bleeding during high-risk procedures and treatment of clinically significant bleeding remains unclear. Viscoelastic measurements of the clotting cascade provide information about platelets, fibrinogen/fibrin polymerization, coagulation factors, and fibrinolysis that might better represent hemostasis in vivo and may better inform management strategies. Due to the paucity of available data, firm recommendations for the use of blood products and pharmacologic agents in patients with hepatic coagulopathies are lacking, and thus, these products should not be routinely administered. Traditional laboratory tests such as PT/INR should not be the sole determinant of potential interventions. Rather, clinicians should assess factors such as the severity of bleed or bleeding risk of the procedure, the patient's risk of thromboembolism, and the strength of available evidence for specific agents and blood products to guide decision-making.
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Affiliation(s)
- Nicholas W Lange
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - David M Salerno
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, 159947Weill Cornell Medicine, New York, NY, USA
- Department of Anesthesiology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology, Department of Medicine, 159947Weill Cornell Medicine, New York, NY, USA
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Lee A, Mendoza J, Brubaker AL, Stoltz DJ, McKenzie R, Bonham CA, Esquivel CO, Gallo AE. Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure. Clin Transplant 2020; 34:e13819. [PMID: 32037570 DOI: 10.1111/ctr.13819] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Transfusion protocols are not well-studied for pediatric patients with acute liver failure (ALF). This study evaluates the utility of an international normalized ratio (INR)-based transfusion threshold for these patients. METHODS Forty-four ALF pediatric patients from 2009 to 2018 were reviewed and divided into two groups: (a) a threshold group including patients between 2009 and 2015 who were transfused for an INR above 3.0, per institutional policy (n = 30), and (b) a post-threshold group including patients after 2015 through 2018 who were transfused based on clinical judgment (n = 14). Preoperative INRs, preoperative transfusions, intraoperative transfusions, early reoperation, renal function, graft function and deaths were compared. RESULTS Liver failure severity was similar between threshold and post-threshold groups. Threshold patients had a lower average INR prior to transplantation, 2.8 (range 1.8-3.8) vs 4.4 (range 2.1-9.0), respectively (P = .01). Twenty-six threshold patients (87%) received preoperative FFP compared with seven post-threshold patients (50%, P = .0088). Two threshold patients (7%) received preoperative cryoprecipitate compared with five post-threshold patients (36%, P = .014). The incidence of pre-transplant bleeding, operative transfusions, and 1-year patient and graft survival did not differ significantly. CONCLUSION Clinical judgment vs an INR-based threshold for transfusions did not increase perioperative complications in children with ALF.
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Affiliation(s)
- Angela Lee
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California
| | - Julianne Mendoza
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University, Stanford, California
| | - Aleah L Brubaker
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California
| | - Daniel J Stoltz
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California
| | - Rebecca McKenzie
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, California
| | - Clark A Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California
| | - Amy E Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California
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The use of a thromboelastometry-based algorithm reduces the need for blood product transfusion during orthotopic liver transplantation. Eur J Anaesthesiol 2019; 36:825-833. [DOI: 10.1097/eja.0000000000001084] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yuen SW, Barrios E, Moon T, Pak T, Smith KM, Toomay S, Cripps MW. Utilization of rotational thromboelastometry (ROTEM) in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). J Clin Anesth 2019; 58:31-32. [PMID: 31059907 DOI: 10.1016/j.jclinane.2019.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Sarah W Yuen
- University of Texas Southwestern Medical Center, Department of Surgery, 6201 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Evan Barrios
- University of Texas Southwestern Medical Center, Department of Surgery, 6201 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Tiffany Moon
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Taylor Pak
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Katelynn M Smith
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Seth Toomay
- University of Texas Southwestern Medical Center, Department of Interventional Radiology, 1801 Inwood Road, Dallas, TX 75390, USA
| | - Michael W Cripps
- University of Texas Southwestern Medical Center, Department of Surgery, 6201 Harry Hines Boulevard, Dallas, TX 75390, USA
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Roullet S, Labrouche S, Freyburger G. Fibrinolysis during liver transplantation: analysis by the Thrombodynamics method. J Clin Pathol 2019; 72:636-638. [PMID: 30975704 DOI: 10.1136/jclinpath-2018-205560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 03/16/2019] [Accepted: 03/25/2019] [Indexed: 12/20/2022]
Abstract
An issue in orthotopic liver transplantation (OLT) is the diagnosis of hyperfibrinolysis. The Thrombodynamics-4D assay (TD4D) is a videomicroscopy system allowing the dynamic analysis of fibrin clot. Fibrinolysis is highlighted by a change in clot intensity. The aim of this observational study was to evaluate the TD4D as a tool to diagnose fibrinolysis during OLT. Thirty consecutive patients were included. We studied a subset of 41 samples from 13 patients who demonstrated hyperfibrinolysis during OLT by global fibrinolytic capacity studied by the Lysis Timer (GFC/LT) and/or euglobulin clot lysis time (ECLT) and/or EXTEM maximum lysis (EXTEM ML) on ROTEM. Three samples exhibited fibrinolysis. They exhibited significantly shorter ECLT, higher lysis on EXTEM graphs, shorter GFC/LT clot lysis time and higher t-PA activity values. After adding urokinase, 13 samples exhibited fibrinolysis. In conclusion, TD4D allows the dynamic analysis of fibrin clot formation and lysis. It only recognises the most severe forms of hyperfibrinolysis during OLT.
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Affiliation(s)
- Stéphanie Roullet
- Service d'Anesthésie Réanimation Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Sylvie Labrouche
- Laboratoire d'hématologie hôpital Pellegrin- PTRR, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Geneviève Freyburger
- Laboratoire d'hématologie hôpital Pellegrin- PTRR, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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Ranucci M, Di Dedda U, Baryshnikova E. Platelet Contribution to Clot Strength in Thromboelastometry: Count, Function, or Both? Platelets 2019; 31:88-93. [DOI: 10.1080/09537104.2019.1581920] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Marco Ranucci
- Department Of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Umberto Di Dedda
- Department Of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ekaterina Baryshnikova
- Department Of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Zamper RPC, Amorim TC, Queiroz VNF, Lira JDO, Costa LGV, Takaoka F, Juffermans NP, Neto AS. Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study. BMC Anesthesiol 2018; 18:198. [PMID: 30579327 PMCID: PMC6303918 DOI: 10.1186/s12871-018-0664-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/03/2018] [Indexed: 02/06/2023] Open
Abstract
Background Perioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation. Methods This is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality. Results A total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20–0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08–0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03–0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality. Conclusions Use of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation. Trial registration This trial was registered retrospectively on November 15th, 2018 – clinicaltrials.gov – Identifier: NCT03756948. Electronic supplementary material The online version of this article (10.1186/s12871-018-0664-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Raffael P C Zamper
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil.
| | - Thiago C Amorim
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Veronica N F Queiroz
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jordana D O Lira
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luiz Guilherme V Costa
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil
| | - Flavio Takaoka
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary S Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Roullet S, Labrouche S, Mouton C, Quinart A, Nouette-Gaulain K, Laurent C, Freyburger G. Lysis Timer: a new sensitive tool to diagnose hyperfibrinolysis in liver transplantation. J Clin Pathol 2018; 72:58-65. [DOI: 10.1136/jclinpath-2018-205280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 12/20/2022]
Abstract
AimsDiagnosis of hyperfibrinolysis in orthotopic liver transplantation (OLT) remains challenging. Euglobulin clot lysis time (ECLT) is not adapted to clinical situations. ROTEM is specific but seldom sensitive to hyperfibrinolysis. The Lysis Timer assesses ‘Global Fibrinolytic Capacity’ in citrated plasma (GFC/LT). GFC/LT associates reagents for in vitro triggering of the clot (thrombin and calcium) and its lysis (tissue-plasminogenactivator (t-PA)), turbidity signal acquisition by the Lysis Timer, and dedicated software converting the digital signal into an optical curve. A visual check of the curves was systematic to ascertain the lysis time values calculated by the software. The primary aim of this prospective observational study was to evaluate the ability of GFC/LT to recognise hyperfibrinolysis during OLT. The secondary aim was to compare its results with ROTEM maximum lysis (EXTEM ML) and with standard laboratory tests.MethodsThirty consecutive adult patients undergoing OLT were included (NCT03012633). Standard laboratory tests, ROTEM, GFC/LT, ECLT and fibrinolysis parameters were assayed at five sample times.ResultsGFC/LT was correlated with ECLT, plasmin activator inhibitor 1 antigen and activity and t-PA activity (r=0.490, 0.681, 0.643 and –0.359, respectively). Hyperfibrinolysis was defined as ECLT ≤60 min. Receiver operating characteristic curve analysis showed that GFC/LT with a threshold of 31 min detected hyperfibrinolysis with a sensitivity of 0.88 (95% CI 0.73 to 0.96), a specificity of 0.68 (95% CI 0.56 to 0.78) and an area under the curve (AUC) of 0.85 (95% CI 0.74 to 0.94). EXTEM ML >12% did not detect hyperfibrinolysis (sensitivity 0.38 (95% CI 0.24 to 0.55), specificity 0.95 (95% CI 0.86 to 0.99) and AUC 0.60 (95% CI 0.46 to 0.75)).ConclusionsGFC/LT recognised hyperfibrinolysis during OLT with a significant agreement with the other tests of fibrinolysis.Trial registration numberNCT03012633.
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Samama CM, Ickx B, Ozier Y, Steib A, Susen S, Godier A. The place of fibrinogen concentrates in the management of perioperative bleeding: A position paper from the Francophone Working Group on Perioperative Haemostasis (GIHP). Anaesth Crit Care Pain Med 2018; 37:355-365. [DOI: 10.1016/j.accpm.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 01/05/2023]
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Effects of Fibrinogen Levels and Platelet Counts on Viscoelastic Testing in Cirrhotic Patients. ACTA ACUST UNITED AC 2018; 4:90-95. [PMID: 30582001 PMCID: PMC6294986 DOI: 10.2478/jccm-2018-0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/02/2018] [Indexed: 12/12/2022]
Abstract
Introduction Cirrhotic patients have been considered for decades to have a pro-haemorrhagic pattern and were treated as such based on the results from standard coagulation tests. The aim of our study was to determine the effects of platelet count and fibrinogen levels on rotational thromboelastometry (ROTEM) parameters. Methods We prospectively included 176 patients with End-Stage Liver Disease (ESLD) admitted to our Intensive Care Unit prior to liver transplantation. Collected data consisted of severity scores, liver, renal and standard coagulation tests, fibrinogen levels, platelet counts and ROTEM parameters. Four ROTEM assays were performed (ExTEM, InTEM, ApTEM and FibTEM) and the following parameters included: CT - clotting time, CFT - clot formation time, MCF - maximum clot firmness, ML - maximum lysis, alpha angle, TPI - thrombin potential index, MaxV - maximum velocity of clot formation (MaxV), MaxVt - time to MaxV, MCE - maximum clot elasticity and AUC - area under the curve. Results Statistical analysis demonstrated a linear correlation between platelet counts and ExTEM TPI (R2 linear =0.494), ExTEM MaxV (R2 linear =0.253), ExTEM MCE (R2 linear = 0.351) and ExTEM MCF (R2 cubic = 0.498). Fibrinogen levels correlated linearly with ExTEM MCF (R2 linear = 0.426), ExTEM TPI (R2 linear = 0.544), ExTEM MaxV (R2 linear = 0.332), ExTEM MCE (R2 linear = 0.395) and non-linearly with ExTEM CFT (R2 cubic = 0.475). Conclusion Fibrinogen levels and platelet counts had an important effect on both standard and derived ROTEM parameters. Further analysis is required in order to determine clinically oriented cut-off values below which severe coagulopathy would develop.
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Herborn J, Lewis C, De Wolf A. Liver Transplantation: Perioperative Care and Update on Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Trautman CL, Palmer WC, Taner CB, Canabal JM, Getz T, Goldman A, Heckman MG, Diehl NN, Lee DD, Stancampiano FF. Thromboelastography as a Predictor of Outcomes Following Liver Transplantation. Transplant Proc 2018; 49:2110-2116. [PMID: 29149970 DOI: 10.1016/j.transproceed.2017.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/12/2017] [Accepted: 07/30/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Thromboelastography (TEG) has been used perioperatively during liver transplantation (LT) to provide a real-time global hemostasis assessment for targeted blood product replacement. We aimed to analyze the relationship between post-LT TEG results and outcomes. METHODS We retrospectively analyzed patients undergoing LT from November 2008 to December 2014 at Mayo Clinic Florida. All 441 single-organ 1st-time LT patients aged ≥18 years requiring post-LT intensive care unit management were included. TEG parameters including r time, k time, α angle, and maximum amplitude were measured regularly during the first 24 hours after LT. Outcomes included return to the operating room secondary to bleeding, length of hospitalization, survival, and early allograft dysfunction. RESULTS A prolonged and/or lengthening r time, k time, and r+k time were all independently associated with increased length of hospitalization after LT. Increased maximum amplitude on the first post-LT TEG was associated with early allograft dysfunction. No notable associations of TEG parameters with survival or return to operating room were observed. CONCLUSIONS The association of absolute and temporal TEG value changes with increased length of hospitalization and early allograft dysfunction suggests that TEG may have a role in identifying patients at high risk for these outcomes.
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Affiliation(s)
- C L Trautman
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - W C Palmer
- Gastroenterology, Mayo Clinic, Jacksonville, Florida.
| | - C B Taner
- Transplant, Mayo Clinic, Jacksonville, Florida
| | - J M Canabal
- Transplant, Mayo Clinic, Jacksonville, Florida
| | - T Getz
- Clinical Research Internship Study Program, Mayo Clinic, Jacksonville, Florida
| | - A Goldman
- Clinical Research Internship Study Program, Mayo Clinic, Jacksonville, Florida
| | - M G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - N N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - D D Lee
- Transplant, Mayo Clinic, Jacksonville, Florida
| | - F F Stancampiano
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
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Cheng F, Yang Z, Zeng J, Gu J, Cui J, Ning J, Yi B. Anesthesia Management of Modified Ex Vivo Liver Resection and Autotransplantation. Ann Transplant 2018; 23:274-284. [PMID: 29700275 PMCID: PMC6248320 DOI: 10.12659/aot.907796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Ex situ liver surgery allows liver resection and vascular reconstruction in patients who have liver tumors located in critical sites. Only a small series of studies about ex situ liver surgery is available in the literature. No anesthesia management experience has been previously published. The aim of the currents study was to summarize our experience with anesthetic management of patients during ex vivo liver surgery. Material/Methods The first 43 patients who received ex vivo liver surgery between January 2007 and April 2012 were included. A pulmonary artery catheter (PAC), transesophageal echocardiography (TEE), and pulse indicator continuous cardiac output (PiCCO) were used intraoperatively in the patients to monitor the hemodynamic changes. Thromboelastogram and the plasma coagulation test were used to monitor the coagulation changes. Results All patients received general anesthesia with rapid sequence induction. The data obtained by PAC, TEE, and PiCOO in these cases showed large changes in hemodynamics during the stages of the first or second vessel reconstruction. The CI decreased about 59%/63% and the MPAP decreased about 49%/37% during the first/second vessel reconstruction. Accurate judgment of the dosage of active drug for vascular support is the key for the stabilization of hemodynamics as quickly as possible. However, a high incidence (35.5%) of prophase fibrinolysis in a long anhepatic phase should be monitored and managed. Conclusions Ex vivo liver surgery is no longer experimental and is a therapeutic option for patients with liver cancer in critical sites. Good anesthesia support is an essential element of liver autotransplantation.
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Affiliation(s)
- Fujun Cheng
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Zhiyong Yang
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jing Zeng
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jianteng Gu
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jian Cui
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jiaoning Ning
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Bin Yi
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
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45
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Roullet S, de Maistre E, Ickx B, Blais N, Susen S, Faraoni D, Garrigue D, Bonhomme F, Godier A, Lasne D. Position of the French Working Group on Perioperative Haemostasis (GIHP) on viscoelastic tests: What role for which indication in bleeding situations? Anaesth Crit Care Pain Med 2018; 38:539-548. [PMID: 29355793 DOI: 10.1016/j.accpm.2017.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Viscoelastic tests (VETs), thromboelastography (TEG®) and thromboelastometry (ROTEM®) are global tests of coagulation performed on whole blood. They evaluate the mechanical strength of a clot as it builds and develops after coagulation itself. The time required to obtain haemostasis results remains a major problem for clinicians dealing with bleeding, although some teams have developed a rapid laboratory response strategy. Indeed, the value of rapid point-of-care diagnostic devices such as VETs has increased over the years. However, VETs are not standardised and there are few recommendations from the learned societies regarding their use. In 2014, the recommendations of the International Society of Thrombosis and Haemostasis (ISTH) only concerned haemophilia. The French Working Group on Perioperative haemostasis (GIHP) therefore proposes to summarise knowledge on the clinical use of these techniques in the setting of emergency and perioperative medicine. METHODS A review of the literature. PRINCIPAL FINDINGS The role of the VETs seems established in the management of severe trauma and in cardiac surgery, both adult and paediatric. In other situations, their role remains to be defined: hepatic transplantation, postpartum haemorrhage, and non-cardiac surgery. They must be part of the global management of haemostasis based on algorithms defined in each centre and for each population of patients. Their position at the bedside or in the laboratory is a matter of discussion between clinicians and biologists. CONCLUSION VETs must be included in algorithms. In consultation with the biology laboratory, these devices should be situated according to the way each centre functions.
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Affiliation(s)
- Stéphanie Roullet
- Inserm U 12-11, service anesthésie-réanimation 1, université de Bordeaux, CHU de Bordeaux, 33000 Bordeaux, France.
| | | | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital, Department of Anesthesiology, Brussels, Belgium
| | - Normand Blais
- Hématologie et oncologie médicale, CHUM, Montréal, Canada
| | - Sophie Susen
- Institut d'hématologie et transfusion, CHRU de Lille, 59037 Lille, France
| | - David Faraoni
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Fanny Bonhomme
- Service d'anesthésiologie, hôpital universitaire de Genève, Geneva, Switzerland
| | - Anne Godier
- Service d'anesthésie-réanimation, Fondation Rothschild, 75019 Paris, France
| | - Dominique Lasne
- Laboratoire d'hématologie, hôpital Necker, 75015 Paris, France
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Forkin KT, Colquhoun DA, Nemergut EC, Huffmyer JL. The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management. Anesth Analg 2018; 126:46-61. [PMID: 28795966 DOI: 10.1213/ane.0000000000002394] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease.
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Affiliation(s)
- Katherine T Forkin
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | | | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Julie L Huffmyer
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth 2017; 22:150-163. [PMID: 29099334 DOI: 10.1177/1089253217739121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.
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Affiliation(s)
- Kevin P Blaine
- 1 Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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Smart L, Mumtaz K, Scharpf D, Gray NO, Traetow D, Black S, Michaels AJ, Elkhammas E, Kirkpatrick R, Hanje AJ. Rotational Thromboelastometry or Conventional Coagulation Tests in Liver Transplantation: Comparing Blood Loss, Transfusions, and Cost. Ann Hepatol 2017; 16:916-923. [PMID: 29055918 DOI: 10.5604/01.3001.0010.5283] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Orthotopic liver transplantation (OLT) can be associated with significant bleeding requiring multiple blood product transfusions. Rotational thromboelastometry (ROTEM) is a point-of-care device that has been used to monitor coagulation during OLT. Whether it reduces blood loss/transfusions during OLT remains controversial. MATERIALS AND METHODS We aim to compare ROTEM with conventional coagulation tests (aPTT, PT, INR, platelet count, fibrinogen) to guide transfusion of platelets, cryoprecipitate, and fresh frozen plasma (FFP) during OLT over 3 years. Thirty-four patients who had transfusions guided by ROTEM were compared to 34 controls who received transfusions guided by conventional coagulation tests (CCT). Intraoperative blood loss, type/ amount of blood products transfused, and direct costs were compared between the two groups. RESULTS The ROTEM group had significantly less intra-operative blood loss (2.0 vs. 3.0 L, p = 0.04) and fresh frozen plasma (FFP) transfusion (4 units vs. 6.5 units, p = 0.015) compared to the CCT group (2.0L vs. 3.0L, p = 0.04). However, total number of patients transfused cryoprecipitate was increased in ROTEM (n = 25;73%) as compared to CCT (n = 19; 56%), p = 0.033. The direct cost of blood products plus testing was reduced in the ROTEM group ($113,142.89 vs. $127,814.77). CONCLUSION In conclusion implementation of a ROTEM-guided transfusion algorithm resulted in a reduction in intra-operative blood loss, FFP transfusion and a decrease in direct cost during OLT. ROTEM is a useful and safe point of care device in OLT setting.
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Affiliation(s)
- Laura Smart
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, KY, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Danielle Scharpf
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nicole O'Bleness Gray
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel Traetow
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anthony J Michaels
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Elmahdi Elkhammas
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Robert Kirkpatrick
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - A James Hanje
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Intagliata NM, Northup PG, Caldwell SH. The Optimal Transfusion Strategy in Liver Transplantation: The Quest Continues. Ann Hepatol 2017; 16:828-829. [PMID: 29055913 DOI: 10.5604/01.3001.0010.5270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Nicolas M Intagliata
- Center for the Study of Coagulation in Liver Disease, University of Virginia, Charlottesville, Virginia, USA
| | - Patrick G Northup
- Center for the Study of Coagulation in Liver Disease, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen H Caldwell
- Center for the Study of Coagulation in Liver Disease, University of Virginia, Charlottesville, Virginia, USA
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Eghbal MH, Samadi K, Khosravi MB, Sahmeddini MA, Ghaffaripoor S, Ghorbani M, Shokrizadeh S. The Impact of Preoperative Variables on Intraoperative Blood Loss and Transfusion Requirements During Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2017; 17:507-512. [PMID: 29025385 DOI: 10.6002/ect.2016.0325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant traditionally and potentially is associated with the risk of massive blood loss and transfusion, which can adversely affect transplant outcomes. Many variables influence the amount of bleeding, and these can be categorized as patient related, surgery related, and graft related. We aimed to assess the effects of these variables on the amount of bleeding and transfusion during liver transplant; predicting the risk of massive blood loss can help transplant teams to select and manage patients more effectively. MATERIALS AND METHODS We retrospectively studied 754 patients who underwent liver transplant from 2013 to 2016 and analyzed more than 20 variables that could influence the volume of blood loss and packed cell transfusion. RESULTS We found that at least 4 variables are strongly and independently correlated with blood loss volume: age, Model for End-Stage Liver Disease score, warm ischemia time, and total bilirubin. Furthermore, intraoperative blood loss had a weak but clinically important correlation with the underlying disease (ie, the cause of liver cirrhosis). Some variables, including international normalized ratio, platelet count, albumin, serum urea nitrogen, creatinine level, sodium level, and the amount of ascites, could be considered as 'dependent' and weak predictors of massive blood loss. Sex of patient, cold ischemia time, surgery technique, and history of previous abdominal surgery were not correlated with the amount of bleeding. CONCLUSIONS With the use of the variables identified, we can properly select patients and surgical teams and promptly use modalities for decreasing and managing blood loss.
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Affiliation(s)
- Mohammad Hossein Eghbal
- From the Department of Anesthesiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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