Perioperative Viscoelastic Assay Use for Monitoring Coagulation Among US Liver Transplantation Centers

Yoon, Uzung; Lai, Manny; Nguyen, Tho; Elia, Elia

doi:10.1016/j.transproceed.2021.07.018

Cited by 5 publications

(4 citation statements)

References 21 publications

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“…Widespread decreases in pro-and anticoagulant factors are typically accompanied by qualitative as well as quantitative defects in platelets and fibrinogen, as well as dysregulation of fibrinolysis. Numerous studies have demonstrated improved correlation of VETs with in vivo clotting function and bleeding compared to CCTs in ESLD 51,52.…”

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confidence: 99%

Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short‐term outcomes after liver transplantation—A systematic review of the literature and expert panel recommendations

Yoon,

Bartoszko,

Bezinover

et al. 2022

Clinical Transplantation

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Background Liver transplantation (LT) is frequently complicated by coagulopathy associated with end‐stage liver disease (ESLD), that is, often multifactorial. Objectives The objective of this systematic review was to identify evidence based intraoperative transfusion and coagulation management strategies that improve immediate and short‐term outcomes after LT. Methods PRISMA‐guidelines and GRADE‐approach were followed. Three subquestions were formulated. (Q); Q1: transfusion management; Q2: antifibrinolytic therapy; and Q3: coagulation monitoring. Results Sixteen studies were included for Q1, six for Q2, and 10 for Q3. Q1: PRBC and platelet transfusions were associated with higher mortality. The use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) were not associated with reductions in intraoperative transfusion or increased thrombotic events. The use of cell salvage was not associated with hepatocellular carcinoma (HCC) recurrence or mortality. Cell salvage and transfusion education significantly decreased blood product transfusions. Q2: Epsilon‐aminocaproic acid (EACA) and tranexamic acid (TXA) were not associated with decreased blood product transfusion, improvements in patient or graft survival, or increases in thrombotic events. Q3: Viscoelastic testing (VET) was associated with decreased allogeneic blood product transfusion compared to conventional coagulation tests (CCT) and is likely to be cost‐effective. Coagulation management guided by VET may be associated with increases in FC and PCC use. Conclusion Q1: A specific blood product transfusion practice is not recommended (QOE; low | Recommendation; weak). Cell salvage and educational interventions are recommended (QOE: low | Grade of Recommendation: moderate). Q2: The routine use of antifibrinolytics is not recommended (QOE; low | Recommendation; weak). Q3: The use of VET is recommended (QOE; low‐moderate | Recommendation; strong).

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confidence: 99%

Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short‐term outcomes after liver transplantation—A systematic review of the literature and expert panel recommendations

Yoon,

Bartoszko,

Bezinover

et al. 2022

Clinical Transplantation

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“…In addition, multiple expert consensus guidelines have emphasized the need for preoperative optimization (for example, nutritional supplementation to reduce anemia and coagulation disorders, and optimization of portal hypertension and renal insufficiency) and the use of viscoelastic testing to reduce blood utilization in liver transplantation 15,16 . A recent survey of USA liver transplantation centers 17 was in agreement with our findings showing the majority (92%) have access to viscoelastic testing, however, only 21% of respondents reported receiving any type of official training in interpretation, indicating its use may not be optimized.…”

Section: Discussionmentioning

confidence: 99%

Blood utilization in liver transplantation (BUILT): A multidisciplinary survey of transfusion practices

et al. 2022

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Background The purpose of this study was to survey liver transplant centers in the United States to assess baseline practices in blood utilization and identify opportunities for standardization to optimize blood use in these complex cases. Study Design and Methods Two surveys, one for transfusion medicine physicians and the other for anesthesiologists, were distributed to high‐volume liver transplant centers. Results The response rate was 52% for both surveys. The majority of respondents (90%) indicated they issue a standardized number of blood products to start surgeries. The most common number of products issued before the start of cases were 10 red blood cells (RBC) and 10 plasma units with no platelets or cryoprecipitate. On average, fewer RBC (7.5) and plasma (7) units were transfused than issued. Decisions to transfuse RhD+ RBCs to RhD‐ patients and use antigen untested units in alloimmunized patients were mainly handled on a case‐by‐case basis. Many centers reported utilizing viscoelastic testing (97%) and cell salvage (97%). Most centers reported standardized, laboratory‐based intraoperative transfusion goals for RBCs (65%) and fibrinogen replacement (52%) but lacked a standardized approach for plasma (55%) and platelets (58%). Discussion More blood products are issued during surgery than are transfused. Responses from anesthesiology providers suggest a broad consensus on practice. Almost all respondents use viscoelastic testing in the management of intraoperative coagulopathy, either alone or in combination with classical coagulation tests. The majority of programs do not transfuse clotting factor concentrates, including fibrinogen concentrate, prothrombin complex concentrates, and recombinant activated FVII, and do not use antifibrinolytics prophylactically.

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“…TEG was introduced by Kang et al in 1985 in liver transplantation [ 8 ]. The ROTEM ® (Instrumentation Laboratory, Bedford, MA, USA) system is a development of the classic TEG and has been used widely in liver transplantation, cardiovascular surgery and trauma, and other clinical settings for coagulation management [ 9 – 11 ]. The system records the kinetic changes during the interaction of platelets with the coagulation factors from initial platelet–fibrin interaction through platelet aggregation, clot strengthening, and fibrin cross-linking to eventual clot lysis [ 12 ].…”

Section: Introductionmentioning

confidence: 99%

A 36-Year-Old Woman with Acute Liver Failure Following Acetaminophen Overdose, Raised INR of 8.7, and Normal Blood Viscosity Measured by Rotational Thromboelastometry (ROTEM)

et al. 2023

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Patient: Female, 36-year-old Final Diagnosis: Liver failure Symptoms: Coagulopathy Medication:— Clinical Procedure: — Specialty: Anesthesiology Objective: Unusual clinical course Background: Fulminant hepatic failure (FHF) is commonly associated with elevated prothrombin time (PT) and international normalized ratio (INR). There is a commensurate decline in pro- and anti-hemostatic factors, and hemostatic function is rebalanced, not reflected in INR. This report presents the case of a 36-year-old woman with FHF following acetaminophen overdose, an increased INR above 8.7, and normal blood viscosity measured by rotational thromboelastometry (ROTEM). Case Report: A 36-year-old woman presented with FHF following an acetaminophen overdose. On arrival, she was lethargic but arousable and followed commands. Her King’s College Criteria for acetaminophen toxicity was 2 and her MELD score was 36. Her INR was unmeasurably high (>8.7). To evaluate whole-blood coagulation, a ROTEM analysis was performed. All parameters (CT, CFT, alpha-angle, A10, MCF) of the NATEM were within reference range. Despite the normal ROTEM, spontaneous bleeding was a concern. The patient received 5 units of cryo-precipitate and 9 units of FFP prior to a central venous line placement. She was started on molecular adsorbent recirculating system and continuous veno-venous hemodialysis, but died on day 7. Conclusions: Patients with FHF can have normal whole-blood coagulation based on ROTEM even if INR levels are unmeasurably high. Viscoelastic tests such as ROTEM, which assesses whole-blood coagulation properties, are preferrable for coagulation monitoring in these patients. Blood product transfusion to correct coagulation abnormality, like FFP and cryoprecipitate, may be used based on the result of viscoelastic testing over conventional coagulation testing.

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Perioperative Viscoelastic Assay Use for Monitoring Coagulation Among US Liver Transplantation Centers

Cited by 5 publications

References 21 publications

Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short‐term outcomes after liver transplantation—A systematic review of the literature and expert panel recommendations

Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short‐term outcomes after liver transplantation—A systematic review of the literature and expert panel recommendations

Blood utilization in liver transplantation (BUILT): A multidisciplinary survey of transfusion practices

A 36-Year-Old Woman with Acute Liver Failure Following Acetaminophen Overdose, Raised INR of 8.7, and Normal Blood Viscosity Measured by Rotational Thromboelastometry (ROTEM)

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