Assessment of standard laboratory tests and rotational thromboelastometry for the prediction of postoperative bleeding in liver transplantation

Dötsch, T.M.; Dirkmann, Daniel; Bezinover, Dmitri; Hartmann, Matthias; Treckmann, Jürgen; Paul, Andreas; Saner, Fuat H.

doi:10.1093/bja/aex122

Cited by 75 publications

(65 citation statements)

References 33 publications

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“…Overall, our results show that only pFB and TEG‐MA were moderately associated with severe bleeding, although their predictive ability was far from optimal. This is in line with the findings of previous publications, which produced heterogeneous results regarding the predictive value of SLTs and viscoelastic tests for bleeding in critically ill patients with coagulopathy. Differences in design, clinical scenarios, and the time of sampling could partially explain these controversial results.…”

Section: Discussionsupporting

confidence: 92%

“…Neither the SLTs nor the TEG parameters seem to differ between hemorrhaging and nonhemorrhaging patients. In fact, ROTEM may be inappropriate for hemostasis assessment in patients with liver cirrhosis and could lead to unnecessary blood transfusions . Overall, all these studies confirm our results, finding only a low‐to‐moderate ability of SLTs and TEG to identify hemorrhaging patients.…”

Section: Discussionsupporting

confidence: 85%

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Relationship of thromboelastography and conventional clotting test values with severe bleeding in critically ill patients with coagulopathy: A prospective study

Casado-Méndez

Fernández-Pacheco

Arellano-Orden

et al. 2019

Int J Lab Hematology

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Introduction This study aimed to ascertain the associations of thromboelastography (TEG®) and standard laboratory test (SLTs) values with the presence of bleeding in critically ill patients with known coagulopathy. Methods Three groups of coagulopathic patients with (a) hepatic failure, (b) postoperative period after prolonged cardiac surgery, and (c) complex abdominal surgery with sepsis were prospectively included in this study. On intensive care unit (ICU) admission, patients were stratified into two groups according to whether they had major bleeding (MB) (evident overt bleeding, important bleeding apparent on imaging studies, and/or need for moderate‐massive blood transfusion and hemodynamic instability). Blood samples were drawn for the SLTs (international normalized ratio [INR], activated partial thromboplastin time [aPTT], platelet count, and fibrinogen level [Clauss]) and TEG whole blood coagulation assays. Receiver operating characteristic (ROC) curves were generated to determine the efficiency of TEG and SLTs for detecting bleeding. The correlations between SLTs and TEG parameters with similar coagulation profiles were evaluated by Spearman rank‐order analysis. Results Eighty‐three patients were included, and bleeding was confirmed in 45 (54%). The fibrinogen level demonstrated the best accuracy for detecting bleeding with an area under the curve and 95% confidence intervals [AUC (95% CI)] of 0.74 (0.63‐0.85) with the best cutoff value of ≤ 2 g/L. Regarding TEG‐MA, the AUC (CI) obtained with the optimal cutoff value of ≤ 51 mm was 0.68 (0.56‐0.80). Conclusions Both conventional clotting tests and TEG values were poorly associated with bleeding in this critically ill cohort of patients with coagulopathy.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 85%

Relationship of thromboelastography and conventional clotting test values with severe bleeding in critically ill patients with coagulopathy: A prospective study

Casado-Méndez

Fernández-Pacheco

Arellano-Orden

et al. 2019

Int J Lab Hematology

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“…Viscoelastic haemostatic assays have a better predictive value for bleeding in liver disease (Fayed et al , ; Tafur et al , ; Pustavoitau et al , ) and re‐bleeding than SLTs (Chau et al , ). A retrospective, single centre study comparing SLT and ROTEM in post‐operative bleeding in adult liver transplant (LT) patients found that several ROTEM parameters predicted bleeding (cut‐offs shown in brackets): EXTEM CT (≥65 s), INTEM CFT (≥181 s), FIBTEM A10 (≤13 mm) and FIBTEM MCF (≤15 mm) (AUC 0·682, 0·615, 0·615 and 0·611 respectively) compared to no SLT tests (Dotsch et al , ). In cirrhotic patients, ROTEM values were associated with bleeding, specifically, reduced EXTEM MCF (median values bleeding vs non‐bleeding: 38 mm vs. 43 mm) and FIBTEM MCF (8 mm vs. 13 mm), and these values were associated with lower factor XIII levels (Bedreli et al , ).…”

Section: Liver Disease and Liver Surgerymentioning

confidence: 99%

The use of viscoelastic haemostatic assays in the management of major bleeding

et al. 2018

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“…Given the theoretical prothrombotic risks of PCC and the limited data on safety for use in ALF, further evaluation is warranted . Nonetheless, studies in liver transplantation suggest a favorable safety profile, and our study also found no association with thrombosis. Descriptions of rFVIIa utilization in ALF patients have been reported in small retrospective single center observational studies; however, its cost is high, and its safety is unclear.…”

Section: Discussionmentioning

confidence: 49%

Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand

Warrillow

Fisher

Tibballs

et al. 2019

J of Gastro and Hepatol

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Background and Aim: To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). Methods: Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. Results: We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62 s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P < 0.0001). Median initial lowest platelet count was 83 (IQR 41-122) × 10 9 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. Conclusion: In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.

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Assessment of standard laboratory tests and rotational thromboelastometry for the prediction of postoperative bleeding in liver transplantation

Abstract: Although both postoperative standard laboratory tests and ROTEM ® assays could identify patients at risk for postoperative bleeding, ROTEM ® assays demonstrated a greater predictive value for impaired fibrinogen polymerization-related coagulopathy.

Cited by 75 publications

References 33 publications

Relationship of thromboelastography and conventional clotting test values with severe bleeding in critically ill patients with coagulopathy: A prospective study

Relationship of thromboelastography and conventional clotting test values with severe bleeding in critically ill patients with coagulopathy: A prospective study

The use of viscoelastic haemostatic assays in the management of major bleeding

Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand

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