Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study

Abstract

BackgroundPerioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation.MethodsThis is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality.ResultsA total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20–0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08–0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03–0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality.ConclusionsUse of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation.Trial registrationThis trial was registered retrospectively on November 15th, 2018 – clinicaltrials.gov – Identifier: NCT03756948.Electronic supplementary materialThe online version of this article (10.1186/s12871-018-0664-8) contains supplementary material, which is available to authorized users.

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

“…Notably, FIBTEM is superior to predict bleeding in liver transplantation compared to plasma fibrinogen concentration since it does not only assess the quantity of fibrinogen but also fibrin polymerization that is affected by dysfibrinogens, factor XIII activity, and colloids [110][111][112][113]. Implementation of FIBTEM-guided fibrinogen substitution in bleeding management algorithms during liver transplantation significantly reduced transfusion requirements for red blood cells, plasma, and platelets [31,92,97,101,[114][115][116][117][118]. In contrast, preemptive administration of fibrinogen concentrate did not influence transfusion requirements in an RCT in liver transplantation [119].…”

“…ROTEM results can also be used to assess the risk for thrombosis, and the 'therapeutic window' concept of ROTEM-guided bleeding management can be used to avoid thromboembolic complications [31,49,97,116,118,126,137]. Hincker et al [137] reported that pre-operative APTT, INR, and platelet count were not able to predict post-operative thromboembolic events after major non-cardiac surgery.…”

“…Implementation of ROTEM-guided bleeding management algorithms as an essential part of PBM resulted in significant reduction in bleeding, transfusion requirements, complication rates, and hospital costs. Here, the highest evidence is available for cardiovascular surgery [32][33][34][35]45,46,54,55,66,69,[214][215][216][217][218] but data supporting the efficacy and safety of ROTEM-guided bleeding management in other clinical settings are increasing [12,[35][36]92,101,[114][115][116][117][118]172,185,186,189,[219][220][221][222][223][224][225][226][227][228]. Accordingly, Deppe et al [34] reported in their meta-analysis including nine RCTs, eight cohort studies and 8332 patients an odds ratio (OR) of 0.63 (95% CI, 0.56-0.71; P < 0.0001) for patients receiving allogeneic blood products, 0.63 (95% CI, 0.50-0.78; P < 0.0001) for RBC transfusion, 0.31 (95% CI, 0.13-0.74; P < 0.0001) for plasma transfusion, 0.62 (95% CI, 0.42-0.92, P = 0.0292) for platelet transfusion, 0.56 (95% CI, 0.45-0.71; P < 0.00001) for re-exploration due to postoperative bleeding, 0.64 (95% CI, 0.31-1.30; P = 0.1345) for cerebrovascular events, 0...…”

Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group

“…[ 63 ] However, with increased expertise, refined surgical skills and improved hemostatic management, the blood loss and subsequent transfusion requirements are decreasing worldwide. [ 64 65 66 67 68 ] In India, liver transplant programs are evolving at most centers. [ 69 ] There are high transfusion requirements and transfusion-associated complications.…”

Management of Patients with Liver Transplantation in ICU

“…The rational use of blood products depends on the monitoring of the coagulation mechanism. Whole-blood viscoelastic tests, such as thromboelastogram (TEG) and rotational thromboelastometry (ROTEM), that illustrate each step of thrombus formation and fibrinolysis are useful tools to guide transfusions and drug administration (anti-fibrinolytics, coagulation factors) [20,21] by limiting the number of transfusions, as there has been an association between them and increased morbidity/mortality, prolonged stay in the hospital, postoperative sepsis, increased risk of acute rejection, and hepatic artery thrombosis [22][23][24].…”