Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation

Abstract

Background: The ability to predict transfusion requirements may improve perioperative bleeding management as an integral part of a patient blood management program. Therefore, the aim of our study was to evaluate preoperative thromboelastometry as a predictor of transfusion requirements for adult living donor liver transplant recipients. Methods: The correlation between preoperative thromboelastometry variables in 100 adult living donor liver transplant recipients and intraoperative blood transfusion requirements was examined by univariate and multivariate linear regression analysis. Thresholds of thromboelastometric parameters for prediction of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusion requirements were determined with receiver operating characteristics analysis. The attending anesthetists were blinded to the preoperative thromboelastometric analysis. However, a thromboelastometry-guided transfusion algorithm with predefined trigger values was used intraoperatively. The transfusion triggers in this algorithm did not change during the study period. Results: Univariate analysis confirmed significant correlations between PRBCs, FFP, platelets or cryoprecipitate transfusion requirements and most thromboelastometric variables. Backward stepwise logistic regression indicated that EXTEM coagulation time (CT), maximum clot firmness (MCF) and INTEM CT, clot formation time (CFT) and MCF are independent predictors for PRBC transfusion. EXTEM CT, CFT and FIBTEM MCF are independent predictors for FFP transfusion. Only EXTEM and INTEM MCF were independent predictors of platelet transfusion. EXTEM CFT and MCF, INTEM CT, CFT and MCF as well as FIBTEM MCF are independent predictors for cryoprecipitate transfusion. Thromboelastometry-based regression equation accounted for 63% of PRBC, 83% of FFP, 61% of cryoprecipitate, and 44% of platelet transfusion requirements. Conclusion: Preoperative thromboelastometric analysis is helpful to predict transfusion requirements in adult living donor liver transplant recipients. This may allow for better preparation and less cross-matching prior to surgery. The findings of our study need to be re-validated in a second prospective patient population.

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

“…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 , ).…”

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

“…1, 2; table 1) [4]. In bleeding patients, a cut-off value of < 75 s seems to be an adequate value to prevent coagulopathic bleeding [27]. …”

The Impact of Preoperative Variables on Intraoperative Blood Loss and Transfusion Requirements During Orthotopic Liver Transplant

“…Fayed and associates 14 demonstrated that most ROTEM variables can accurately predict packed RBCs, fresh frozen plasma, cryoprecipitates, and platelet transfusion needs; however, this test is expensive and is not routinely performed before liver transplant. More economic models for prediction of blood loss risk are needed as they are more practical and cost effective.…”