Point-of-care haemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome

León-Justel, Antonio; Noval-Padillo, J. A.; Álvarez-Ríos, Ana Isabel; Mellado, Patricia; Bravo, Miguel Ángel Gómez; Álamo, J.M.; Porras, Manuel; Barrero, Lydia; Hinojosa, R.; Carmona, María Teresa Padilla; Vilches-Arenas, Angel; Guerrero, Juan M.

doi:10.1016/j.cca.2015.04.022

Cited by 59 publications

(52 citation statements)

References 34 publications

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“…Leon-Justel et al [25] conducted a prospective trial in 200 liver transplantation patients. The first 100 patients were treated with an SLT-guided hemostatic management protocol while the other 100 patients received ROTEM-guided hemostatic management.…”

Section: Bleeding Management In Patients With End-stage Liver Diseasementioning

confidence: 99%

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

Saner

Kirchner

2016

Visc Med

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Background: Patients with end-stage liver disease (ESLD) are assumed to be at high risk of bleeding when undergoing any kind of invasive intervention (any kind of operation, including transplantation or minimally invasive interventions). Both bleeding and thrombosis are associated with a poor outcome. Methods: A selective literature research was conducted with the following key words: ‘cirrhosis', ‘coagulation', ‘bleeding', ‘INR' (international normalized ratio), ‘aPTT' (activated partial thromboplastin time), and ‘thrombocytopenia'. PubMed was used as the basic database. Results: Pathological values of standard laboratory tests (SLT) and thrombocytopenia have traditionally been regarded as indicators of a high risk for bleeding in all patients, and especially in those with ESLD. However, this approach has been challenged in recent years. The conventional approach in assessing a bleeding risk was based on pathological values of SLT. A 1.5-fold increase of INR or aPTT or platelets < 50/nl is assumed as pathological. The traditional approach of reducing the risk of excessive bleeding during an invasive procedure was to transfuse fresh frozen plasma (FFP) or platelet concentrates in order to improve hemostasis and to avoid bleeding complications. In the recent 20 years, several studies have provided us with a basis for questioning this approach. Their results indicated that SLT were not able to predict hypocoagulation and bleeding complications. Moreover, transfusion of various blood products has been associated with an increased risk for acute lung injury, transfusion-associated circulation overload, bacterial infections, and modulation of the immune system with increased numbers of nosocomial infections. Furthermore, a high volume overload, which is required to correct a hemostasis disorder if FFP are being used in ESLD patients, may increase portal venous pressure. This might significantly increase bleeding in these ESLD patients. Although the first publication about the successful use of a viscoelastic test (VET) in liver transplantation dates back to 1985, physicians are still very reluctant to use VETs (Thrombelastography™ and/or ROTEM™) for the perioperative optimization of hemostasis. However, some very recent studies demonstrated that the use of VETs for assessing the risk of bleeding avoids futile transfusion with a similar safety profile. The implementation of ROTEM-based coagulation management and the use of coagulation factors (prothrombin complex, fibrinogen concentrate) have led to a highly significant reduction of FFP and red blood cell transfusions, without an increased incidence of thrombosis or bleeding. Conclusion: Patients with ESLD often show pathological values of conventional parameters used to analyze coagulation hemostasis. Without overt signs of excessive bleeding, however, they do not require coagulation treatment. The use of FFP, which is associated with fluid overload and increase in portal venous pressure, should be avoided. The preferable coagulation treatment should be based on VET-g...

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Section: Bleeding Management In Patients With End-stage Liver Diseasementioning

confidence: 99%

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

Saner

Kirchner

2016

Visc Med

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“…This intricate procedure associated with considerable risk and substantial haemorrhage may require vast blood product replacement . A great range of allogenic transfusion rates exists across transplantation centres worldwide, regardless, blood product transfusion within this population is linked with adverse postoperative outcomes and mortality . The pathogenesis of coagulopathy and subsequent haemorrhage in OLT remains multifactorial .…”

Section: Orthotopic Liver Transplant Surgerymentioning

confidence: 99%

Point‐of‐care viscoelastic assay devices (rotational thromboelastometry and thromboelastography): a primer for surgeons

Sharp

Young

2018

ANZ Journal of Surgery

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Background: Bleeding is a common occurrence in surgery. Point-of-care testing with viscoelastic (VE) assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) has become more common place. TEG and ROTEM have the potential to guide management of coagulopathy. Many healthcare professionals still rely upon standard laboratory tests (SLTs) to manage a bleeding patient. It was our aim to investigate the literature surrounding management of the surgically bleeding patient via VE assays. Methods: Literature review of Embase, MEDLINE, PubMed and the Cochrane Library using 'TEG, ROTEM and surgery' search terms was conducted. Results: Through the literature search and reference lists reviewed by both authors, a total of 62 articles have been evaluated, 35 of these have been included in this review. Conclusion: VE assays are used most commonly during orthotopic liver transplantation, trauma, postpartum haemorrhage and cardiac surgery. Although the evidence is not overwhelming, we have identified recurrent themes where VE assays seem to be beneficial. VE assay use, especially when incorporated into an algorithm, appears to reduce blood product administration which in turn reduces cost and potential adverse events. They are quicker than SLTs and they can detect hyperfibrinolysis, the hallmark of coagulopathy, via in vivo clot analyses which SLTs are unable to do. Ultimately more randomized controlled trials are required.

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“…Additionally, in the postoperative phase, the early functional recovery of the transplanted liver is important to reach normal haemostasis. Surgical techniques, the length of anhepatic phase, complications in logistics, the overall experience of the team and the duration of the procedure are additional factors leading to varying blood usage. Intraoperative blood salvage may reduce the usage of allogeneic blood products.…”

Section: Blood Loss and Transfusion In Sotmentioning

confidence: 99%

Choosing the right blood products for transplant patients

Gabriel

2016

ISBT Science Series

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Improving transfusion safety is a one corner stone for continuous improvements in haematopoietic stem cell and solid-organ transplantation. In this setting, additional selection and methods are applied to blood products to ensure a sophisticated transfusion practice to support patients with high risk of bleeding as well as patients in chronic demand. Furthermore, transfusion product selection for solid-organ and stem cell transplantation is very similar if focused on the avoidance of viral infections and adverse immune reactions.

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Point-of-care haemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome

Cited by 59 publications

References 34 publications

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

Point‐of‐care viscoelastic assay devices (rotational thromboelastometry and thromboelastography): a primer for surgeons

Choosing the right blood products for transplant patients

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