Hemostasis in Children Undergoing Liver Transplantation

Abstract

We reviewed the records of 200 children who underwent 238 orthotopic liver transplantations in order to determine which preoperative factors could predict intraoperative blood loss. A coagulation abnormality score (CAS) was calculated by allowing one point for each abnormality in six preoperative coagulation tests. The mean CAS values were significantly greater in children suffering from fulminant hepatic failure (Fulm) or post-necrotic cirrhosis (PNC) and those having retransplantation (ReTx) than in those with disease of other etiologies. No correlation was found between the CAS and the mean blood requirements in the different etiology groups. According to the amount of blood transfused, children could be divided in two groups. Group 1 were those with biliary atresia and ReTx, who received more than 200 ml/kg. Group 2 included those with PNC, Fulm, metabolic diseases, and Alagille syndrome and Byler disease, who received less than 140 ml/kg. The mean CAS was significantly lower and the PT significantly better in Group 1. We conclude that preoperative coagulation tests were weak predictors of intraoperative bleeding. The etiology of the underlying liver disease and previous abdominal surgery play an important role in the occurrence of severe bleeding. Intraoperatively, children presented the same hemostatic changes as adults.

Réduire les pertes sanguines et les besoins transfusionnels en chirurgie pédiatrique

“…1,5,[27][28][29][30] For pediatric liver transplants, apart from retransplantation, factors that have been associated with increased intraoperative blood losses include: hypoplastic portal vein, use of a reduced-size liver graft, requirement of in-hospital supportive care, intra-abdominal malformations and signs of severe liver failure (encephalopathy, ascites, prolonged PT). 20,[31][32][33] Children younger than two years, and particularly those under one year of age experience higher blood loss. 34,35 Transplantation of a reduced (fraction of an adult human organ) liver not only increases intra-and postoperative blood loss, but has been associated with an increase in the percentage of patients undergoing reoperation for continued blood loss, from 9.6 to 19.2%.…”

Hemostatic Abnormalities and Liver Diseases

“…43,44 TMA is also reported to be one of the most important complications in liver transplantation. 5,45 Perioperative defects in the hemostasis system can be extensive and depend on the underlying disease. They usually resemble those illustrated in Table 4.…”

“…The reticuloendothelial system (RES) of the liver greatly participates in the clearance of breakdown products of activated clotting factors such as fibrin-related products, thrombin-antithrombin complex (TAT), plasmin-plasmin-inhibitor complex (PPIC), and activated platelets. Prof. Mammen was an early pioneer in the investigation of various hemostatic abnormalities associated with many liver diseases including liver cirrhosis, and several liver abnormalities due to liver transplantation 5 or bone marrow transplantation 6 have been recently noted.…”

Haemostatic disorders during liver transplantation

“…Table 2 summarizes some of these studies each of which comes from a different Institution involving a minimum of 50 patients with at least two haemostasis assays. However, most authors failed to ®nd any correlation between preoperative haemostatic pro®le and blood requirements in adults [23,24] or children [22,25]. Two studies found a relationship between abnormalities in some preoperative coagulation tests and blood requirements.…”