Coagulation Techniques Are Not Important In Directing Blood Product Transfusion During Liver Transplantation

Abstract

Preoperative acquired clotting parameters such as prothrombin time, activated partial thromboplastin time, antithrombin III, platelet concentration, and fibrinogen show coagulopathy caused by insufficiency of the diseased liver. Intraoperative determination of clotting factors or parameters is not helpful to direct intraoperative transfusion of blood, blood components, or platelets because transfusions performed solely for correction of clotting data do not correlate with the real intraoperative requirements and increase the costs of orthotopic liver transplantation. However, the use of antihyperfibrinolytic drugs seems to reduce intraoperative blood loss. Patients with cirrhotic disorders caused by portalvenous hypertension show extensive collaterals and increased intravascular blood volume. Thus it is plausible that especially overcorrection of blood loss during the surgical preparation in the preanhepatic phase of the operation results in extensive blood loss. Therefore, to avoid blood loss we attempt to keep volume substitution to a minimum during the preanhepatic phase of the operation. In contrast, during the anhepatic and postanhepatic phases we attempt to reestablish normovolemia by transfusing red packed blood cells and fresh-frozen plasma. Strictly confined use of blood products in the preanhepatic phase, followed by later correction of intravascular blood volume, may reduce intraoperative blood loss; it also seems to ensure adequate substitution of clotting factors.

Intraoperative red blood cell transfusion in liver transplantation: Influence on patient outcome, prediction of requirements, and measures to reduce them

“…This observation supports the principle that blood component use during LT should be based on clinical assessment and a well-established transfusion protocol, rather than laboratory tests. 17,18 Because of the low blood cell volume transfused in our patients, we believe use of intraoperative autotransfusion would increase the complexity of LT without adding great advantages. Groups that use intraoperative autotransfusion have reported greater transfusion rates than ours.…”

Thrombelastography/thromboelastometry

“…However, the increased use of component therapy resulted in the same number of donor exposures for the recipient (Kang et al, 1985). The absence of guidelines and any clear evidence as to the most appropriate thresholds has left questions with regard to the clinical use of algorithm-based replacement therapy in hepatic surgery (Reyle-Hahn & Rossaint, 1997).…”

Liver Transplantation

“…During the recipient hepatectomy measurement and prophylactic treatment of abnormal laboratory bleeding time (BT), PT, INR, and aPTT have been common practice in order to help control anticipated surgical bleeding. However, as early as 1997, it was identified that aggressively correcting laboratory coagulation abnormalities prior to the anhepatic phase of transplantation is not required and that over-resuscitation during the pre-anhepatic phase may lead to extensive blood loss [91]. Prophylactic administration of FFP and RBCs contributes to blood loss by increasing splanchnic pressure in an already hyperdynamic circulatory state.…”