Haemostatic management for aortic valve replacement in a patient with advanced liver disease

Table 1 Perioperative laboratory values and heparinase thromboelastography results

	Ref. ranges	Pre-operative	Pre-CPB	Rewarming Haemostatic intervention: FFP 15 mg/kg	Immediately post separation from CPB Haemostatic intervention: Protamine 500 mg; DDAVP 0.3 mg/kg; Concentrated fibrinogen 4 g;Platelets 2 pooled doses; 2 units packed RBC	15 min post separation from CPB Haemostatic intervention: Prothrombine × 1000 IU; then continuous infusion at 100 IU /h	30-min post separation from CPB Haemostatic intervention: Nil	Arrival intensive care unit
R (min)	4-8	6.4	5.0	6.7	6.9	28.9	7.8	6.7
K (min)	0-4	2.0	1.8	1.8	1.8	4.9	1.5	1.6
Angle (deg)	47-74	62.7	63.5	65.6	65.2	49.6	68.5	65.5
MA (mm)	54-72	53.7	61.9	61.3	57.6	71.8	69.0	70.1
LY30 (%)	0-8	0.7	0.3	0.0	0.0	1.4	0.0	0.0
INR	-	1.3	1.2	1.4	1.7	1.5	1.4	1.4
PT	11-15 s	13 s	14 s	15 s	19 h	17 h	16 h	16 h
APPT	22-38 s	36 s	39 h	> 200 h	49 h	50 h	45 h	38 s
Fib clauss	2.0-4.0 g/L		2.3 g/L	1.3 L	2.6 g/L	2.0 g/L	1.6 L	1.8 g/L
D-dimer	< 0.23 mg/L	1.05 h	Not measured	0.94 h		1.15 mg/L	Not measured	Not measured
Hb	130-180/L	90 L	83 L	73 L	55 L	85 L	Not measured	71 L
WBC	4.0-11.0 × 109	3.9 L	4.2 × 109	10.8 × 109	8.2 × 109	11.7 h	Not measured	9.4 × 109
Platelets	150-400 × 109	76 L	64 L	57 L	140 L	120 L	Not measured	73 L

The thromboelastography was performed after each of haemostatic interventions described. CPB: Cardiopulmonary bypass; FFP: Fresh frozen plasma; DDAVP: Desmopressin acetate; INR: International normalised ratio; PT: Prothrombin time; APPT: Activated partial prothrombin time; WBC: White blood cells; RBC: Red blood cells; MA: Maximum amplitude; K: Clot formation time; R: Reaction time.

Table 2 Perioperative arterial blood gases

	Ref. ranges	Pre-operation	Pre-cardiopulmonary bypass	Rewarming	Post separation	Closure	Post-op day 1	Post-op day 2 (venous)
pH	7.35-7.45	7.341	7.321	7.371	7.241	7.341	7.341	7.331
pCO2 (mmHg)	35-45	37	38	35	502	42	39	45
pO2 (mmHg)	80-110	105	2302	3882	3852	4042	1112	331
HCO3- (mmol/L)	-	19	19	20	20	22	20	23
Base excess (mmol/L)	-3/+3	-61	-61	-41	-61	-3	-51	-2
O2 sat (%)	> 94	98	100	100	100	100	100	561
Na+ (mmol/L)	135-148	1321	1322	136	138	138	138	1301
K+ (mmol/L)	3.5-5.3	4.0	4.0	4.9	3.9	3.9	4.6	4.5
Cl- (mmol/L)	95-106	1071	1072	106	1082	1082	106	99
Ionised Ca2+ (mmol/L)	1.13-1.32	1.16	1.071	0.921	0.831	1.061	1.101	1.101
Haemoglobin (g/L)	120-180	801	781	711	771	861	711	631
Glucose (mmol/L)	0.0-5.0	5.92	6.32	8.32	6.22	3.81	8.02	8.92
Lactate (mmol/L)	3.9-5.8	0.9	0.6	4.02	2.92	2.02	1.5	1.3

¹Value below reference range;

²Value above reference range.

Table 3 Perioperative renal function and liver function tests

	Ref. ranges	Pre-op	Arrival in ICU	Day 1 post op
Urea (mmol/L)	3.2-7.3	8.72	6.3	7.62
Creatinine (μmol/L)	62-106	1102	91	1252
Albumin (g/L)	35-52	31	251	36
Globulins (g/L)	25-35	462	191	201
Bilirubin (μmol/L)	< 18	40	352	472
ALP (IU)	40-130	99	51	49
ALT (IU)	< 41	30	21	22
GGT (U/L)	< 60	1002	40	40

¹Value below reference range;

²Value above reference range. ICU: Intensive care unit; ALP: Alkaline phosphatase; ALT: Alanine aminotransferase; GGT: Gamma-glutamyl transpeptidase.