A clinical coagulopathy score concurrent with viscoelastic testing defines opportunities to improve hemostatic resuscitation and enhance blood product utilization during liver transplantation

Schulick, Alexander; Moore, Hunter B.; Walker, Carson B.; Yaffe, Hillary; Pomposelli, James J.; Azam, Fareed; Wachs, Michael; Bak, Thomas; Kennealey, Peter; Conzen, Kendra D.; Adams, Megan; Pshak, Thomas; Choudhury, Rashikh A.; Chapman, Michael P.; Pomfret, Elizabeth A.; Nydam, Trevor L.

doi:10.1016/j.amjsurg.2020.07.034

Cited by 13 publications

(13 citation statements)

References 32 publications

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“…Although this observation might help explain the paucity of significant bleeding events, the accuracy of TEG to predict bleeding complications has not been established, even though the assay is used to guide blood‐component repletion during liver transplantation. ( 11 ) Although TEG represents blood clot formation in a more “physiologic” environment than the INR (i.e., in whole blood), the assay lacks endothelial factors and is usually initiated by adding an industrial clay, also arguably un‐physiologic.…”

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confidence: 99%

Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

et al. 2021

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confidence: 99%

Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

et al. 2021

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“…The advantages of viscoelastic whole blood coagulation assessment include the point‐of‐care accessibility and the acquisition of rapid results which is immensely valuable to transplant anesthesiologists. Increasing numbers of studies report the success of this technology in standardized approaches in the management of operative bleeding and support the widespread use of this technology in this context 15,16 …”

Section: Discussionmentioning

confidence: 96%

“…Increasing numbers of studies report the success of this technology in standardized approaches in the management of operative bleeding and support the widespread use of this technology in this context. 15,16 Pharmacologic based treatment of coagulopathy remains rare, with the exception of anti-fibrinolytic medication use; however, even these are used less commonly now. Previous reports indicated that 50-60% of programs routinely administered anti-fibrinolytics during liver transplantation 5 whereas our results demonstrated average use a quarter of cases.…”

Section: Intraoperative Management Techniquesmentioning

confidence: 99%

Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia

Crouch

Sakai

Aniskevich

et al. 2021

Clinical Transplantation

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Introduction: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. Methods: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). Results:Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys. Conclusion:The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.

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“…It has been suggested that VET should be considered as an adjunct to conventional coagulation testing in order to provide a robust assessment of coagulation in patients undergoing liver surgery. 58,60 However, it is important to note some limitations to this systematic review and meta-analysis. The present analysis was prospectively planned to be restricted to RCTs utilizing thromboelastography, and RCTs reporting data on the use of TEG 5000 and MonoTEM-A only were included in the analysis; therefore, the results cannot be assumed to be directly transferable to other devices.…”

Section: Discussionmentioning

confidence: 99%

Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials

Hartmann

Dias

Pivalizza

et al. 2022

Semin Thromb Hemost

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Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03–0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30–0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.

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A clinical coagulopathy score concurrent with viscoelastic testing defines opportunities to improve hemostatic resuscitation and enhance blood product utilization during liver transplantation

Cited by 13 publications

References 32 publications

Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia

Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials

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