Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery

Abstract

Plasma-containing products are given during the pre-anhepatic stage of liver transplant surgery to correct abnormal thromboelastogram (TEG) values and prevent blood loss due to coagulation defects. However, evidence suggests that abnormal TEG results do not always predict bleeding. We questioned what effect using higher TEG values to initiate treatment would have on blood loss. A single transfusion protocol was used for all patients who underwent liver transplantation between 2007 and 2010. Thirty-eight patients received coagulation products when standard TEG cutoff values were exceeded, whereas another 39 patients received coagulation products when the TEG values were 35% greater than normal. The results of postoperative coagulation tests for total blood loss and the use of blood products were compared for the 2 groups. When the critical TEG values for transfusion were higher, significantly fewer units of fresh frozen plasma (5.58 6 6.49 versus 11.53 6 6.66 U) and pheresis platelets (1.84 6 1.33 versus 3.55 6 1.43 U) were used. There were no differences in blood loss or postoperative blood product use. In conclusion, the use of higher critical TEG values to initiate the transfusion of plasma-containing products is not associated with increased blood loss. Further testing is necessary to identify what TEG value predicts bleeding due to a deficit in coagulation factors. Liver Transpl 18:1254-1258, 2012. V C 2012 AASLD.Received October 10, 2011; accepted June 13, 2012.Blood transfusions in liver transplant recipients are associated with an increased risk of infection and lung injury.1 This leads to increases in morbidity and mortality.2 Other outcome studies have shown that intraoperative transfusions of plasma products significantly reduce 1-year survival 3-5 and increase morbidity in liver transplant recipients. 6Physicians have used the thromboelastogram (TEG) as a tool for identifying abnormal coagulation. TEG can discriminate between different phases of the coagulation system and is, therefore, useful for identifying clotting abnormalities and guiding the administration of blood products.In 2007, we reported using less frozen plasma in transplant patients when transfusions were guided by standard TEG cutoff values instead of the international normalized ratio (INR)/prothrombin time and platelet counts. 7 We concluded that TEG was a

Clinical applicability of rapid thrombelastography and functional fibrinogen thrombelastography to adult liver transplantation

“…First, although this study is a prospective study, the number of patients enrolled was small in comparison with other studies assessing the utility of r‐TEG in adult and pediatric trauma patients. However, the number of patients in our study was similar to that of other studies assessing the utility of traditional k‐TEG in LT patients . In addition, according to our initial power calculation, we needed only 16 patients to detect a correlation greater than 0.6.…”

Balanced blood product transfusion during liver transplantation

“…While conventional coagulation testing was used to determine the need for transfusion in our study, viscoelastic testing has gained popularity as a method of directing and decreasing transfusion during OLT . However, there is a lack of consensus on what thromboelastography values need to be corrected to what end‐points given the unique coagulation profile of cirrhotic patients . Moreover, thromboelastography has yet to be associated with a definitive mortality benefit in OLT.…”

Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference

“…Although data from clinical trials are lacking, these tests are widely used in the setting of liver transplantation to manage major hemorrhage or to trigger blood transfusion. Even in this setting, the threshold values of ROTEM/TEG parameters for triggering transfusion of hemostatic agents (such as fresh frozen plasma), remains to be determined [27], even though in a randomized study significantly fewer units of fresh frozen plasma (FFP) or blood were needed at the time of liver transplantation in patients monitored by TEG [28]. These promising results warrant larger confirmatory studies.…”