In 97 adult patients receiving liver transplants, the coagulation system was monitored by thrombelastography and by coagulation profile including PT; aPTT; platelet count; level of factors I, II, V, VII, VIII, IX, X, XI, and XII; fibrin degradation products; ethanol gel test; protamine gel test; and euglobulin lysis time. Preoperatively, fibrinolysis defined as a whole blood clot lysis index of less than 80% was present in 29 patients (29.9%), and a euglobulin lysis time of less than 1 h was present in 13 patients. Fibrinolysis increased progressively during surgery in 80 patients (82.5%) and was most severe on reperfusion of the graft liver in 33 patients (34%). When whole blood clot lysis (F < 180 min) was observed during reperfusion of the graft liver, blood coagulability was tested by thrombelastography using both a blood sample treated in vitro with ε-aminocaproic acid (0.09%) and an untreated sample. Blood treated with ε-aminocaproic acid showed improved coagulation without fibrinolytic activity in all 74 tests. When whole blood clot lysis time was less than 120 min, generalized oozing occurred, and the effectiveness of ε-aminocaproic acid was demonstrated in vitro during the pre-anhepatic and post-anhepatic stages, ε-aminocaproic acid (1 g, single intravenous dose) was administered. In all 20 patients treated with ε-aminocaproic acid, fibrinolytic activity disappeared; whole blood clot lysis was not seen on thrombelastography during a 5-h observation period, and whole blood clot lysis index improved from 28.5 ± 29.5% to 94.8 ± 7.4% (mean ± SD, P < 0.001). None of the treated patients had hemorrhagic or thrombotic complications. In patients undergoing liver transplantation, the judicious use of a small dose of ε-aminocaproic acid, when its efficacy was confirmed in vitro, effectively treated the severe fibrinolysis without clinical thrombotic complications.
KeywordsBlood; coagulation; fibrinolysis; Liver; transplantation; Measurement techniques; thrombelastography; Pharmacology; ε-aminocaproic acid Orthotopic liver transplantation is frequently associated with surgical bleeding that requires massive blood transfusion. 1 The surgical bleeding is compounded by preexisting coagulopathy, dilutional coagulopathy, fibrinolysis, and, possibly, disseminated intravascular In a recent series of patients undergoing liver transplantation, the degree of coagulopathy and volume of transfusion decreased with the introduction of replacement therapy guided by the frequent thrombelastographic monitoring of the coagulation system and the use of heparin-coated veno-venous bypass. 3,4 However, active fibrinolysis, manifest as generalized oozing from a previously dry surgical field and unresponsive to replacement therapy, has been a major difficulty in the intraoperative management of liver transplantation.Since the early experience in hepatic transplantation, activation of the fibrinolytic system has been recognized, 5,6 and, although antifibrinolytic treatment appears beneficial, it has been used only sporadically. Vo...
