Perioperative Coagulation Management in Liver Transplant Recipients

Bezinover, Dmitri; Dirkmann, Daniel; Findlay, James Y.; Guta, Cosmin; Hartmann, Matthias; Nicolau‐Raducu, Ramona; Mukhtar, Ahmed; Moguilevitch, Marina; Pivalizza, Evan G.; Rosenfeld, David M.; Saner, Fuat H.; Wray, Christopher; Wagener, Gebhard; West, James M.

doi:10.1097/tp.0000000000002092

Cited by 74 publications

(88 citation statements)

References 177 publications

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“…We simultaneously treat severe consumptive coagulopathy (DIC), or DIC‐like TEG patterns with enhanced fibrinolysis, with both heparin (to inhibit coagulation activation) plus an antifibinolytic (to inhibit fibrinolytic activation; Figure ) . The combination minimizes the risk of catastrophic intravascular thrombosis that is known to occur with antifibrinolytic therapy alone …”

Section: Discussionmentioning

confidence: 99%

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Nicolau‐Raducu

Livingstone

Salsamendi

et al. 2019

Clinical Transplantation

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Multivisceral transplant (MVT) for cirrhosis, and portomesenteric vein thrombosis (PVT), is fraught with life-threatening thrombo-hemorrhagic complications.Embolization of native viscera has been attempted in a handful of cases with mixed results. We carried out a comparative analysis of angiographic, intra-operative, and pathological findings in three recipients of MVT who were deemed exceptionally high hemorrhagic risk and therefore underwent preoperative visceral embolization.All recipients were male with cirrhosis, PVT, and a surgical history indicative of diffuse visceral adhesions; status post-liver transplantation (n = 2) and proctocolectomy (n = 1). The first patient had two Amplatzer II embolization plugs placed 2 cm from the origins of celiac and superior mesenteric (SMA) arteries. Distal migration of the celiac plug into gastroduodenal artery (GDA) and ensuing ischemia reperfusion injury, presumably contributed to severe disseminated intravascular coagulation (DIC) and intra-operative mortality. In the other two recipients, distal Gelfoam embolization of the SMA, GDA, and splenic arteries was performed, and although remarkable hemorrhage and coagulopathy occurred, embolization, undoubtedly, facilitated exenteration and improved outcomes. Pathologic examination in these cases confirmed ischemic necrosis of eviscerated bowel. In conclusion, liver-sparing, preoperative distal embolization of native viscera with Gelfoam is beneficial, but entails several pitfalls. It should currently be reserved for MVT recipients who otherwise are at unacceptably high risk.

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Section: Discussionmentioning

confidence: 99%

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Nicolau‐Raducu

Livingstone

Salsamendi

et al. 2019

Clinical Transplantation

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“…Although caution is always warranted, thrombotic risk with these agents is low unless there is an identified preexisting hypercoagulable state. 50,51 Two recent meta-analyses examining the use of antifibrinolytics in GI bleeding and liver transplantation have not demonstrated increased thrombosis risk. 52,53 Antifibrinolytic use has reduced the need for blood products perioperatively in liver transplant, 52 and application of topical forms, in particular, is low risk and may be a useful adjunct for persistent bleeding.…”

Section: Mucosal and Wound Oozing In The Icu Patient With Liver Diseasementioning

confidence: 99%

“…70,71 Although individual transplant centers typically have algorithm-based guidance for the management of bleeding intra-and postoperatively, general guidelines and transfusion goals are well summarized in a recent review. 50…”

Section: Perioperative Coagulation Management In Liver Transplantmentioning

confidence: 99%

Coagulation Pathways, Hemostasis, and Thrombosis in Liver Failure

Intagliata

Davis

Caldwell

2018

Semin Respir Crit Care Med

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Achieving hemostasis, preventing and treating thrombosis, and laboratory measurement of the hemostatic pathways constitute the core elements of managing the critically ill patient with liver failure. Uncontrolled bleeding in acutely decompensated cirrhosis and acute-on-chronic liver failure is probably the most familiar clinical challenge to intensivists. Bleeding in these patients can be broadly divided into pressure-driven (portal hypertension-related) bleeding with only limited dependence on hemostatic pathways and intractable mucosal/wound bleeding, which is much more directly related to a severely disturbed hemostatic system with imbalances in the coagulation cascade and the fibrinolytic system. Both types of bleeding can occur simultaneously and may even coexist with inappropriate thrombosis such as portal vein thrombosis or venous thromboembolism. Due to the fundamental role of the liver in coagulation factor synthesis and its direct and indirect regulation of nearly all aspects of the hemostatic system, laboratory measurements of coagulation pathways also constitute key aspects of all prognostic scores that guide clinical decisions and forecast optimal interventions in both acute and chronic forms of liver failure.

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“…Perioperative coagulation management in pediatric liver transplant patients continues to be a moving target. Both end‐stage liver disease and ALF lead to simultaneously hyper‐ and hypo‐coagulable states, resulting in an increased risk for both thromboembolic and bleeding complications . Perioperatively, these severe coagulopathies can trigger frequent transfusions in order to prevent bleeding and pre‐transplant death .…”

Section: Introductionmentioning

confidence: 99%

Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure

Lee

Mendoza

Brubaker

et al. 2020

Clinical Transplantation

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Introduction Transfusion protocols are not well‐studied for pediatric patients with acute liver failure (ALF). This study evaluates the utility of an international normalized ratio (INR)‐based transfusion threshold for these patients. Methods Forty‐four ALF pediatric patients from 2009 to 2018 were reviewed and divided into two groups: (a) a threshold group including patients between 2009 and 2015 who were transfused for an INR above 3.0, per institutional policy (n = 30), and (b) a post‐threshold group including patients after 2015 through 2018 who were transfused based on clinical judgment (n = 14). Preoperative INRs, preoperative transfusions, intraoperative transfusions, early reoperation, renal function, graft function and deaths were compared. Results Liver failure severity was similar between threshold and post‐threshold groups. Threshold patients had a lower average INR prior to transplantation, 2.8 (range 1.8‐3.8) vs 4.4 (range 2.1‐9.0), respectively (P = .01). Twenty‐six threshold patients (87%) received preoperative FFP compared with seven post‐threshold patients (50%, P = .0088). Two threshold patients (7%) received preoperative cryoprecipitate compared with five post‐threshold patients (36%, P = .014). The incidence of pre‐transplant bleeding, operative transfusions, and 1‐year patient and graft survival did not differ significantly. Conclusion Clinical judgment vs an INR‐based threshold for transfusions did not increase perioperative complications in children with ALF.

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Perioperative Coagulation Management in Liver Transplant Recipients

Cited by 74 publications

References 177 publications

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Coagulation Pathways, Hemostasis, and Thrombosis in Liver Failure

Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure

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