Management of bleeding and transfusion during liver transplantation before and after the introduction of a rotational thromboelastometry–based algorithm

Abstract

Orthotopic liver transplantation (OLT) remains a potentially hemorrhagic procedure. Rotational thromboelastometry (ROTEM) is a point-of-care device used to monitor coagulation during OLT. Whether it allows blood loss and transfusions to be reduced during OLT remains controversial. Excellent correlations and predictive values have been found between ROTEM parameters and fibrinogen. We hypothesized that the use of a ROTEM-based transfusion algorithm during OLT would lead to more fibrinogen transfusion and decreased bleeding and blood transfusion. Sixty adult patients were consecutively included in a prospective, without-versus-with study: 30 in the group without ROTEM results and 30 in the group with the ROTEM-based algorithm. A small and nonsignificant increase in median fibrinogen transfusions was found for the with group (6.0 g versus 4.5 g, P 5 0.50). It was not associated with a decrease in blood transfusions or in the number of patients exposed to blood products. Liver Transpl 21:169-179, 2015. V C 2014 AASLD.Received June 26, 2014; accepted October 12, 2014.Orthotopic liver transplantation (OLT) remains a surgical procedure associated with major bleeding despite recent advances in the understanding and management of coagulation defects.1-3 Rotational thromboelastometry (ROTEM) is a point-of-care device used to monitor coagulation during cardiac surgery, for trauma patient care, and during OLT. 4,5 Good correlations have been found between ROTEM and laboratory results in the setting of OLT, 6,7 and transfusion algorithms have been implemented by anesthesia teams. However, ROTEM's ability to reduce blood loss and transfusions during OLT remains controversial. 8,9 ROTEM use is recommended by the European Society of Anaesthesiology.10 After a first study in which we gained experience and evaluated correlations between ROTEM parameters and standard laboratory tests, 6 we conducted a prospective, comparative withoutversus-with study to evaluate the impact of a ROTEM-based transfusion algorithm on transfusions and bleeding during OLT. We also performed laboratory blood analyses to manage blood cell counts and Abbreviations: A10, clot amplitude at 10 minutes; aPTT, activated partial thromboplastin time; AUC, area under the curve; ELT, euglobulin lysis time; FFP, fresh frozen plasma; ICU, intensive care unit; NPV, negative predictive value; OLT, orthotopic liver transplantation; PPV, positive predictive value; RBC, red blood cell; ROC, receiver operating characteristic; ROTEM, rotational thromboelastometry; TEG, thromboelastography.St ephanie Roullet and François Sztark have received honoraria from LFB Biom edicaments for lectures.LFB Biom edicaments and Tem-International financed the leasing of the rotational thromboelastometry device and provided the rotational thromboelastometry reagents.Address reprint requests to St ephanie Roullet, M.D., Service d'Anesth esie R eanimation 1

Impact of Preemptive Fibrinogen Concentrate on Transfusion Requirements in Liver Transplantation: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial

“…In the single trial evaluating the influence of fibrinogen administration on blood transfusion in LT, an observational study by Roullet and coworkers (15) found that a thromboelastometry-based algorithm led to increased fibrinogen transfusion; however, like us, they saw no decrease in blood transfusions. To our knowledge, ours is the only completed randomized trial to assess the efficacy of preemptive fibrinogen administration in LT.…”

The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products – A systematic review and meta-analysis

“…Manuscript not available for reading. Contact information of corresponding author not available.Karkouti 2016 [61]Cardiac surgeryStepped-Wedge Clustered RCTLevin 2014 [62]Cardiac surgeryFocus on protamine-administrationLier 2009 [63]TraumaReviewMallaiah 2015 [64]Obstetric haemorrhageBefore-after trialManikappa 2011 [65]Cardiac surgeryWhole blood transfusionsMessenger 2011 [66]TraumaProspective cohort studyMishra 2015 [67]Cardiac surgeryFocus on platelet function testingNaik 2015 [68]Major spinal surgeryNon-randomisedPetricevic 2013 [69]Cardiac surgeryObservational trialRahe-Meyer 2009 [70]Aortic surgeryNon-randomisedRoullet 2015 [71]Orthotopic liver transplantationNon-randomisedSmart 2015 [72]Orthotopic liver transplantationRetrospective non-randomised trialStancheva 2011 [73]Orthotopic liver transplantationObservational trialTarabarin 2013 [74]Bile duct surgeryPossibly relevant. Manuscript not available for reading.…”

Lysis Timer: a new sensitive tool to diagnose hyperfibrinolysis in liver transplantation

“…Transfusion algorithm was based on core lab and ROTEM results as already described 6. Tranexamic acid (TXA) administration was guided by typical ROTEM traces of hyperfibrinolysis (EXTEM ML >15%),14 15 and/or oozing in the surgical field with no macroscopic clot formation and/or bleeding exceeding one blood volume.…”