An <i>in vitro</i> study comparing two dose regimes of fresh frozen plasma on conventional and thromboelastographic tests of coagulation after major hepatic resection

Schofield, Nick; Sugavanam, Anita; Henley, Matthew; Thompson, Kiley; Riddell, Anne; Mallett, Susan

doi:10.1111/tme.12194

Cited by 6 publications

(7 citation statements)

References 34 publications

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“…These findings therefore question the practice of administering prophylactic FFP before invasive procedures purely to reduce a perceived bleeding risk if the INR ≤ 2, or indeed the need to delay removal of epidural catheters until the INR returns to normal range. Although transfusion of FFP will partially correct an elevated INR following liver resection, it has no measurable effect on viscoelastic parameters that are already within normal range . Our data support the need for early initiation of thromboprophylaxis, and this is paradoxically of even more importance in patients with more extensive resections and consequently higher INR values.…”

Section: Discussionmentioning

confidence: 50%

Alterations in coagulation following major liver resection

Mallett

Sugavanam²,

Krzanicki

et al. 2016

Anaesthesia

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SummaryThe international normalised ratio is frequently raised in patients who have undergone major liver resection, and is assumed to represent a potential bleeding risk. However, these patients have an increased risk of venous thromboembolic events, despite conventional coagulation tests indicating hypocoagulability. This prospective, observational study of patients undergoing major hepatic resection analysed the serial changes in coagulation in the early postoperative period. Thrombin generation parameters and viscoelastic tests of coagulation (thromboelastometry) remained within normal ranges throughout the study period. Levels of the procoagulant factors II, V, VII and X initially fell, but V and X returned to or exceeded normal range by postoperative day five. Levels of factor VIII and Von Willebrand factor were significantly elevated from postoperative day one (p < 0.01). Levels of the anticoagulants, protein C and antithrombin remained significantly depressed on postoperative day five (p = 0.01). Overall, the imbalance between pro-and anticoagulant factors suggested a prothrombotic environment in the early postoperative period.

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Section: Discussionmentioning

confidence: 50%

Alterations in coagulation following major liver resection

Mallett

Sugavanam²,

Krzanicki

et al. 2016

Anaesthesia

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“…While immediately post resection both standard coagulation testing and TEG values indicated a normocoagulable state, up to POD5 TEG revealed a hypercoagulable state with decreased r time, whereas standard coagulation testing indicated a hypocoagulable status. This discrepancy between standard coagulation testing and TEG was also observed in the Schofield et al, 29 Banz et al 30 and Tanner et al 18 studies. Specifically, despite the prolongation in INR after hepatectomy, TEG did not demonstrate evidence of hypocoagulability in the study by Schofield et al 29 In another study, microparticle tissue factor and procoagulant activity increased after liver resection along with overall coagulation as assessed by TEG, whereas standard coagulation testing indicated normocoagulability.…”

Section: Standard Coagulation Testing and Viscoelastic Testing Parame...mentioning

confidence: 59%

“…This discrepancy between standard coagulation testing and TEG was also observed in the Schofield et al, 29 Banz et al 30 and Tanner et al 18 studies. Specifically, despite the prolongation in INR after hepatectomy, TEG did not demonstrate evidence of hypocoagulability in the study by Schofield et al 29 In another study, microparticle tissue factor and procoagulant activity increased after liver resection along with overall coagulation as assessed by TEG, whereas standard coagulation testing indicated normocoagulability. 30 Similar findings were observed in the study by Tanner et al with TEG demonstrating a hypercoagulable profile in 64%, 33%, 39% and 36% of patients following hepatectomy on POD0, POD1, POD3 and POD5, respectively.…”

Section: Standard Coagulation Testing and Viscoelastic Testing Parame...mentioning

confidence: 59%

“…48 Similar to that, in major liver resections where alterations in coagulation are complex and highly dependent on the pre-existing liver dysfunction, the presence of malignancy, extent of intra-operative blood loss, surgical technique, ischemia-reperfusion injury as well as the volume of the liver remnant post resection, 49 ROTEM testing can significantly aid in predicting bleeding risk when compared with the standard coagulation testing. 15,29,50 Several limitations need to be considered when interpreting the results of the present systematic review. There was a large heterogeneity in patient characteristics and indications for resection (benign vs malignant disease) among individuals analyzed in the present review.…”

Section: Discussionmentioning

confidence: 99%

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Utility of viscoelastic coagulation testing in liver surgery: a systematic review

Mpaili

Tsilimigras

Moris

et al. 2021

HPB

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“…In contrast, hemostasis management guided by viscoelastic testing has been shown to reduce transfusion requirements in patients with cirrhosis [19,20]. DePietri et al [42], Schofield et al [43], and Mallet et al [44] demonstrated a disagreement between conventional coagulation testing and viscoelastic testing regarding hypo- and hypercoagulability in patients undergoing major liver resection. Herbstreit et al [45] is in -line with our finding that CT in thromboelastometry shows poor correlation with both PT and aPTT in patients with cirrhosis.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Thromboelastometry for Adult Living Donor Liver Transplant Recipients with a Tendency to Hypercoagulability: A Prospective Observational Cohort Study

Kamel

Hassanin

Ahmed

et al. 2018

Transfus Med Hemother

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Background: Hypercoagulability can lead to serious thromboembolic events. The aim of this study was to assess the perioperative coagulation status in liver transplant recipients with a tendency to hypercoagulability. Methods: In a prospective observational study (South African Cochrane Registry 201405000814129), 151 potential liver transplant recipients were screened for thrombophilic factors from October 2014 to June 2017, and 57 potential recipients fulfilled the inclusion criterion of presenting two or more of the following thrombophilic factors: low protein C, low protein S, low anti-thrombin, increased homocystein, increased antiphospholipid IgG/IgM antibodies, increased lupus anticoagulant, and positive Factor V Leiden mutation. Seven patients were excluded from the study because they fulfilled the exclusion criteria of cancelling the liver transplantation, oral anticoagulation, or intraoperative treatment with rFVIIa. Accordingly, 50 patients were included in the final analysis. Thromboelastometry (ROTEM) (EXTEM, INTEM and FIBTEM) and conventional coagulation tests (CCT) were performed preoperatively, during the anhepatic phase, post reperfusion, and on postoperative days (POD) 1, 3 and 7. ROTEM was used to guide blood product transfusion. Heparin was infused (60-180 U/kg/day) postoperatively for 3 days and then was replaced by low-molecular-weight heparin (20 mg/12 h). Results: FIBTEM MCF significantly increased postoperatively above reference range on POD 7 despite normal fibrinogen plasma concentrations (p < 0.05). Both EXTEM and INTEM demonstrated significant changes with the phases of transplantation (p < 0.05), but with no intra- or postoperative hypercoagulability observed. INTEM CT (reference range, 100-240 s) normalized on POD 3 and 7 (196.1 ± 69.0 and 182.7 ± 63.8 s, respectively), despite prolonged aPTT (59.7 ± 18.7 and 46.4 ± 15.7 s, respectively; reference range, 20-40 s). Hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) were reported in 12.0% and 2.0%, respectively, mainly after critical care discharge and with high FIBTEM MCF values in 57% on POD 3 and 86% on POD 7. Receiver operating characteristics curve analyses of FIBTEM MCF were significant predictors for thromboembolic events with optimum cut-off, area under the curve and standard error on POD 3 (>23 mm, 0.779 and 0.097; p = 0.004) and POD 7 (>28 mm, 0.706 and 0.089; p = 0.020). Red blood cells (mean ± SD, 8.68 ± 5.81 units) were transfused in 76%, fresh frozen plasma (8.26 ± 4.14 units) in 62%, and cryoprecipitate (12.0 ± 3.68 units) in 28% of recipients. None of the recipients received intraoperative platelet transfusion or any postoperative transfusion. Main transplant indication was hepatitis C infection in 82%. 76% of recipients included in this highly selected patient population showed increased lupus anticoagulant, 2% increased antiphospholipid IgG/IgM antibodies, 20% increased homocysteine, 74% decreased anti-thrombin, 78% decreased protein C, 34% decreased protein S, and 24% a positive Factor V Leiden mutation....

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An in vitro study comparing two dose regimes of fresh frozen plasma on conventional and thromboelastographic tests of coagulation after major hepatic resection

Abstract: Despite the rise in INR after hepatectomy, VET do not show evidence of hypocoagulability. In vitro addition of FFP had no significant effect on TEG parameters. Clinical use of FFP in this situation is questionable.

Cited by 6 publications

References 34 publications

Alterations in coagulation following major liver resection

Alterations in coagulation following major liver resection

Utility of viscoelastic coagulation testing in liver surgery: a systematic review

Perioperative Thromboelastometry for Adult Living Donor Liver Transplant Recipients with a Tendency to Hypercoagulability: A Prospective Observational Cohort Study

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