Case Report:A 38 years old patient was scheduled for fetal MMC in utero repair. The fetus presented a lumbosacral MMC and Arnold Chiari type II malformation. Magnesium sulfate was administered for fetal neuroprotection. We provided a latex free environment (LFE). Uterine relaxation (UR) was achieved by indomethacin, atosiban, nitroglycerin and sevoflurane. Rapid sequence intubation was performed using fentanyl, propofol and rocuronium. Anesthesia maintenance was achieved by target controlled infusion (TCI) of remifentanil, sevoflurane and fentanyl. Bispectral Index (BIS) was used to monitor depth of anesthesia. As there is a known risk of pulmonary edema 1 , we decided to maintain a goal directed fluid management, using EV1000® to estimate systolic volume variation and cardiac output. Norepinephrine was used to maintain maternal blood pressure. Fentanyl, atropine and vecuronium were administered intramuscularly to the fetus. Fetal heart rate was registered by echocardiography. Surgery was completed without any maternal or fetal complications.

Cardiohepatic transplantation represents a double hemostatic challenge. Given the absence of specific guidelines and current evidence, we designed a 5-step approach based on rotational thromboelastometry (ROTEM). A 60-year-old male patient with cirrhosis and myocarditis underwent a 9-hour transplantation. Bleeding occurred after weaning from extracorporeal circulation. Evidence of reduced clot strength triggered fibrinogen and platelet replacement therapy. During liver transplant, only hemoglobin optimization was necessary. In conclusion, hemostatic management protocols for cardiohepatic transplants should consider the specific coagulopathy mechanisms underlying each surgical phase. Because whole blood testing is essential for their diagnosis, we recommend using ROTEM for optimal coagulation management.

Background and Goal of StudyEnd stage liver disease (ESLD) patients are characterized by a rebalanced haemostatic system. This represents a paradigm shift, abandoning the concept of "auto-anticoagulation" based on alterations of standard laboratory test (SLT). Viscoelastic tests emerge as a more suitable alternative. The aim of this study was to evaluate the correlation between SLT and ROTEM results at the beginning of orthotopic liver transplantation (OLT).