The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management

Abstract

The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease.

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

“…Although INR has been a popular reference point to assess coagulopathy, systematic reviews have found it to be an incomplete indicator of coagulation status and a poor predictor of intraoperative bleeding risk . Similar to our findings, studies in cirrhotic adult liver transplant patients have found that preprocedural transfusion to a specific INR threshold did not translate to differences in periprocedural blood transfusions .…”

Potential for Orogastric Tube Attached Transesophageal Echocardiography to Improve Intraoperative Image Quality

“…22 However, this can be concerning in cardiac cases in which full heparinization is necessary, in aortic stenosis patients who have acquired von Willebrand disease and angiodysplasia, 23 and in end-stage liver disease patients who commonly have esophageal or gastric varices as well as coagulopathy. 24 Especially for aortic valvulopathy patients or aortic valve procedures, transgastric or deep transgastric TEE views are useful for assessment of aortic valve pressure gradient and valve integrity, and it is important to minimize unnecessary manipulations of the TEE probe.…”

Reducing risk of spinal haematoma from spinal and epidural pain procedures

“…Thomas [5] and Thomas et al [33] studied safe epidural catheter removal with advanced haemostatic viscoelastic tests and found the tests not well validated in this context; there are frequent false negative (apparently normal) test results. However, a clearly abnormal TEG ® or ROTEM ® curve indicates deranged haemostasis, and must be taken seriously [5,34]. Factor Xa activity can be measured, and where available, can be an important help in evaluating bleeding risk from factor Xa inhibitors (Table 2b).…”

“…factor deficiencies, but also imbalance between production and destruction of platelets, resulting in thrombocytopenia [73]. Reductions in both pro-and anti-coagulant factors seem to be able to balance each other, and platelet dysfunction is compensated, at least in part, by a concomitant increase in the von Willebrand factor [34,72]. In patients with liver cirrhosis, the risk of systemic thromboembolism can be greater than the risk of bleeding [34].…”