Preoperative thrombelastography maximum amplitude predicts massive transfusion in liver transplantation

Abstract

Introduction Massive transfusion (MT) is frequently required during liver transplantation. Risk stratification of transplant patients at risk for MT is an appealing concept, but remains poorly developed. Thrombelastography (TEG) has recently been shown to reduce mortality when employed for trauma resuscitation. We hypothesize that preoperative TEG can be used to risk stratify patients for massive transfusion. Material and Methods Liver transplant patients had blood drawn prior to surgical incision and assayed via TEG. Pre-operative TEG measurements were collected in addition to standard laboratory coagulation tests. TEG variables including R-time (reaction time), angle, MA (maximum amplitude), and LY30 (clot lysis 30 minutes after MA) were correlated to red blood cell (RBC) units, plasma (FFP), cryoprecipitate (Cryo), and platelets (Plt) during the first 24 hours following surgery, and tested for their performance using a receiver operating characteristic (ROC) curve. Results 28 patients were included in the analysis with a median MELD (Model for End-Stage Liver Disease) score of 17; 36% received a massive transfusion. The TEG variables associated with MT (defined as ≥10 RBC units/24hr) were a low MA (p<0.001) and low angle (p=0.014). A high INR (International Normalized Ratio of prothrombin time) (p=0.003) and low platelet count (p=0.007) were also associated with massive transfusion. MA had the highest area under the curve (0.861) followed by INR (0.803). A MA of less than 47mm has a sensitivity of 90% and specificity of 72% to predict a massive transfusion. MA was the only coagulation variable that correlated strongly to all blood products transfused. Conclusion TEG MA has a high predictability of massive transfusion during liver transplantation. The use of TEG pre-operatively may help guide more cost effective blood bank preparation for this procedure as only a third of patients required a massive transfusion.

Effect of Coagulation Status and Co-Morbidity on Flap Success and Complications in Patients with Reconstructed Free Flap

“…Many studies have shown that TEG has detected hypercoagulation in the clinical setting. However, there is no consensus on the evaluation of the results due to differences in the types of operations and the methodologies applied, and the results of the studies are contradictory (6,7,(20)(21)(22). Dai et al (7) examined 10 studies that aimed at predicting postoperative thromboembolic events with TEG, and, as a result, they stated that although TEG is reported to be beneficial, all studies reported differences in methodologies.…”

Predicting packed red blood cell transfusion in living donor liver transplantation: A retrospective analysis

“…[ 25 ] Indeed, in a single-centre study, maximum amplitude less than 47 mm on TEG predicted the need for MT in liver transplantation. [ 26 ] In our centre, FFP and other blood product transfusions were guided by TEG in the presence of clinical oozing. On no occasion was FFP transfused as a fixed ratio with PRBC.…”

Thromboelastography and Utility in Hepatology Practice

“…In particular, preoperative values of TEG (low MA) have been shown to predict need for massive transfusion during liver transplantation. 18 Significant postperfusion bleeding from hyperfibrinolysis may occur during liver transplantation, and both ROTEM and TEG can assist in recognition and management of this challenging physiology. [19][20][21] Hypercoagulability is also of concern during liver transplantation, and thrombotic events can be catastrophic.…”