Antifibrinolytics in liver surgery

Abstract

Hyperfibrinolysis, a known complication of liver surgery and orthotopic liver transplantation (OLT), plays a significant role in blood loss. This fact justifies the use of antifibrinolytic drugs during these procedures. Two groups of drug namely lysine analogues [epsilon aminocaproic acid (EACA) and tranexamic acid (TA)] and serine-protease-inhibitors (aprotinin) are frequently used for this purpose. But uniform data or guidelines on the type of antifibrinolytic drugs to be used, their indications and correct dose, is still insufficient. Antifibrinolytics behave like a double-edged sword. On one hand, there are benefits of less transfusion requirements but on the other hand there is potential complication like thromboembolism, which has been reported in several studies. We performed a systematic search in PubMed and Cochrane Library, and we included studies wherein antifibrinolytic drugs (EACA, TA, or aprotinin) were compared with each other or with controls/placebo. We analysed factors like intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality. Among the three drugs, EACA is least studied. Use of extensively studied drug like aprotinin has been restricted because of its side effects. Haemostatic effect of aprotinin and tranexamic acid has been comparable. However, proper patient selection and individualized treatment for each of them is required. Purpose of this review is to study various clinical trials on antifibrinolytic drugs and address the related issues like benefits claimed and associated potential complications.

Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study

“…Hyperfibrinolysis is an important cause of bleeding in patients undergoing liver transplantation [64]. Thus, antifibrinolytic drugs are used to reduce blood loss and transfusion of blood components, reducing costs and complications, and the decision to use this resource should be individualized because of the theoretical risk of thromboembolic events, which is still a matter of debate [65, 66]. The high incidence of fibrinolysis disturbances found in patients undergoing liver transplantation has made the use of antifibrinolytics desirable in the past, with the exclusion of patients who are more prone to thrombotic events, such as patients with inflammatory diseases of the biliary tract, previous history of thrombotic events and patients with cellular hepatocarcinoma or other types of cancer.…”

Tranexamic acid therapy for postoperative bleeding after bariatric surgery

“…Perioperative tranexamic acid in patients undergoing total knee arthroplasty resulted in a significant reduction in mean blood loss compared to placebo (940 mL and 1293 mL) [ 9 ]. During liver transplantation, intravenous infusion of tranexamic acid resulted in clinical benefits without episodes of arterial or venous thrombosis [ 18 ]. In spine surgery tranexamic acid reduced intraoperative, postoperative, and total blood loss of 219 mL, 119 mL, and 202 mL respectively.…”

Fibrinolytic System Changes in Liver Surgery: A Pilot Observational Study

“…Liver surgery on its own right, and the use of the Pringle maneuver with major endothelial damage, can reduce hepatic perfusion, increase hepatocellular dysfunction and promote a hyper-fibrinolytic state ( 8 , 20 , 21 ). Therefore, prophylaxis with anti-fibrinolytic agents are recommended in patients scheduled for liver surgery ( 22 – 24 ). Although, all the patients received a prophylactic dose of 10 mg/kg of tranexamic acid after induction of anesthesia, its modulating effect on the activation of fibrinolysis and bleeding is still questionable.…”