Download PDF
Semin Thromb Hemost 2015; 41(05): 538-546
DOI: 10.1055/s-0035-1550428
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Classical Notions of Coagulation Revisited in Relation with Blood Losses, Transfusion Rate for 700 Consecutive Liver Transplantations

Luc Massicotte
1   Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
,
Lynda Thibeault
2   Department of Public Health, University of Montreal, Montreal, Quebec, Canada
,
André Roy
3   Department of Hepatopancreatobilliary Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
› Author Affiliations
Further Information

Publication History

Publication Date:
16 June 2015 (online)

    Permissions and Reprints

Abstract

During the last decade, improved surgical and anesthetic management, such as better understanding of coagulation defects and the use of the phlebotomy, has reduced intraoperative blood product transfusions during orthotopic liver transplantation (OLT). The goal of this study was to look at the impact of initial conventional coagulation tests on blood loss and blood product requirement and to evaluate the role of the phlebotomy during liver transplantations. A total of 700 consecutive OLTs were studied. The group of patients was split into two according to the median of starting international normalized ratio to study blood losses and transfusion rate. Logistic regression was used to determine the main predictors of blood loss, intraoperative blood transfusion, and survival. There was no intergroup difference for demographic characteristics. The mean blood loss was 1,184 mL with a median of 920 mL. Overall, 77.4% of the patients did not receive any blood product and the mean transfusion rate of red blood cells (RBCs) was 0.5 ± 1.4 units per patient. Severity of recipients' disease did not correlate with blood loss or transfusion rate. Starting hemoglobin value was the only biochemical variable linked to RBC transfusions. Phlebotomy was linked to decrease in blood loss, RBC transfusions, and increased survival rate. It is concluded that bleeding did not correlate with traditional coagulation defects or the severity of recipient's disease. Preemptive phlebotomy was linked to a decreased blood loss, a decreased transfusion rate, and an increased 1-year survival rate.

Keywords

liver transplantation - coagulation - transfusion - phlebotomy - antifibrinolytic - cell saver - MELD score
 

  • References

  • 1 Butler P, Israel L, Nusbacher J, Jenkins Jr DE, Starzl TE. Blood transfusion in liver transplantation. Transfusion 1985; 25 (2) 120-123
    CrossrefPubMedGoogle Scholar
  • 2 de Boer MT, Molenaar IQ, Hendriks HGD, Slooff JH, Porte RJ. Minimizing blood loss in liver transplantation: progress through research and evolution of techniques. Dig Surg 2005; 22 (4) 265-275
    CrossrefPubMedGoogle Scholar
  • 3 Cacciarelli TV, Keeffe EB, Moore DH , et al. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg 1999; 134 (1) 25-29
    CrossrefPubMedGoogle Scholar
  • 4 Massicotte L, Capitanio U, Beaulieu D, Roy J-D, Roy A, Karakiewicz PI. Independent validation of a model predicting the need for packed red blood cell transfusion at liver transplantation. Transplantation 2009; 88 (3) 386-391
    CrossrefPubMedGoogle Scholar
  • 5 Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Reduction of blood product transfusions during liver transplantation. Can J Anaesth 2005; 52 (5) 545-546
    CrossrefPubMedGoogle Scholar
  • 6 Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg 2004; 98 (5) 1245-1251
    PubMedGoogle Scholar
  • 7 Ramos E, Dalmau A, Sabaté A , et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl 2003; 9 (12) 1320-1327
    CrossrefPubMedGoogle Scholar
  • 8 Shan WL, Barkun J, Metrakos P, Tchervenkov J, Backman SB. Blood product use during orthotopic liver transplantation. Can J Anaesth 2004; 51 (10) 1045-1046
    CrossrefPubMedGoogle Scholar
  • 9 Hevesi ZG, Lopukhin SY, Mezrich JD, Andrei AC, Lee M. Designated liver transplant anesthesia team reduces blood transfusion, need for mechanical ventilation, and duration of intensive care. Liver Transpl 2009; 15 (5) 460-465
    CrossrefPubMedGoogle Scholar
  • 10 Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365 (2) 147-156
    CrossrefPubMedGoogle Scholar
  • 11 Massicotte L, Denault AY, Beaulieu D , et al. Transfusion rate for 500 consecutive liver transplantations: experience of one liver transplantation center. Transplantation 2012; 93 (12) 1276-1281
    CrossrefPubMedGoogle Scholar
  • 12 Planinsic RM, van der Meer J, Testa G , et al. Safety and efficacy of a single bolus administration of recombinant factor VIIa in liver transplantation due to chronic liver disease. Liver Transpl 2005; 11 (8) 895-900
    CrossrefPubMedGoogle Scholar
  • 13 Lodge JP, Jonas S, Jones RM , et al; rFVIIa OLT Study Group. Efficacy and safety of repeated perioperative doses of recombinant factor VIIa in liver transplantation. Liver Transpl 2005; 11 (8) 973-979
    CrossrefPubMedGoogle Scholar
  • 14 Ozier Y, Pessione F, Samain E, Courtois F ; French Study Group on Blood Transfusion in Liver Transplantation. Institutional variability in transfusion practice for liver transplantation. Anesth Analg 2003; 97: 671-679
    PubMedGoogle Scholar
  • 15 Reyle-Hahn M, Rossaint R. Coagulation techniques are not important in directing blood product transfusion during liver transplantation. Liver Transpl Surg 1997; 3 (6) 659-663 , discussion 663–665
    CrossrefPubMedGoogle Scholar
  • 16 Dupont J, Messiant F, Declerck N , et al. Liver transplantation without the use of fresh frozen plasma. Anesth Analg 1996; 83 (4) 681-686
    PubMedGoogle Scholar
  • 17 Massicotte L, Beaulieu D, Thibeault L , et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008; 85 (7) 956-962
    CrossrefPubMedGoogle Scholar
  • 18 Massicotte L, Beaulieu D, Roy J-D , et al. MELD score and blood product requirements during liver transplantation: no link. Transplantation 2009; 87 (11) 1689-1694
    CrossrefPubMedGoogle Scholar
  • 19 Massicotte L, Denault AY, Beaulieu D, Thibeault L, Hevesi Z, Roy A. Aprotinin versus tranexamic acid during liver transplantation: impact on blood product requirements and survival. Transplantation 2011; 91 (11) 1273-1278
    CrossrefPubMedGoogle Scholar
  • 20 Massicotte L, Thibeault L, Beaulieu D, Roy JD, Roy A. Evaluation of cell salvage autotransfusion utility during liver transplantation. HPB (Oxford) 2007; 9 (1) 52-57
    CrossrefPubMedGoogle Scholar
  • 21 Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl 2006; 12 (1) 117-123
    CrossrefPubMedGoogle Scholar
  • 22 Massicotte L, Perrault MA, Denault AY , et al. Effects of phlebotomy and phenylephrine infusion on portal venous pressure and systemic hemodynamics during liver transplantation. Transplantation 2010; 89 (8) 920-927
    CrossrefPubMedGoogle Scholar
  • 23 Ozier Y, Klinck JR. Anesthetic management of hepatic transplantation. Curr Opin Anaesthesiol 2008; 21 (3) 391-400
    CrossrefPubMedGoogle Scholar
  • 24 Mukhtar A, Salah M, Aboulfetouh F , et al. The use of terlipressin during living donor liver transplantation: Effects on systemic and splanchnic hemodynamics and renal function. Crit Care Med 2011; 39 (6) 1329-1334
    CrossrefPubMedGoogle Scholar
  • 25 Steib A, Freys G, Lehmann C, Meyer C, Mahoudeau G. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth 2001; 48 (11) 1075-1079
    CrossrefPubMedGoogle Scholar
  • 26 McCluskey SA, Karkouti K, Wijeysundera DN , et al. Derivation of a risk index for the prediction of massive blood transfusion in liver transplantation. Liver Transpl 2006; 12 (11) 1584-1593
    CrossrefPubMedGoogle Scholar
  • 27 Rahe-Meyer N, Solomon C, Hanke A , et al. Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology 2013; 118 (1) 40-50
    CrossrefPubMedGoogle Scholar
  • 28 Fries D. The early use of fibrinogen, prothrombin complex concentrate, and recombinant-activated factor VIIa in massive bleeding. Transfusion 2013; 53 (Suppl. 01) 91S-95S
    CrossrefPubMedGoogle Scholar
  • 29 Innerhofer P, Westermann I, Tauber H , et al. The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases transfusion rates in patients with major blunt trauma. Injury 2013; 44 (2) 209-216
    CrossrefPubMedGoogle Scholar
  • 30 Massicotte L, Sassine MP, Lenis S, Seal RF, Roy A. Survival rate changes with transfusion of blood products during liver transplantation. Can J Anaesth 2005; 52 (2) 148-155
    CrossrefPubMedGoogle Scholar
  • 31 Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg 2009; 108 (4) 1083-1091
    CrossrefPubMedGoogle Scholar
  • 32 Boyd SD, Stenard F, Lee DK, Goodnough LT, Esquivel CO, Fontaine MJ. Alloimmunization to red blood cell antigens affects clinical outcomes in liver transplant patients. Liver Transpl 2007; 13 (12) 1654-1661
    CrossrefPubMedGoogle Scholar
  • 33 Hendriks HG, van der Meer J, de Wolf JT , et al. Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation. Transpl Int 2005; 17 (11) 673-679
    CrossrefPubMedGoogle Scholar
  • 34 Boin IF, Leonardi MI, Luzo AC, Cardoso AR, Caruy CA, Leonardi LS. Intraoperative massive transfusion decreases survival after liver transplantation. Transplant Proc 2008; 40 (3) 789-791
    CrossrefPubMedGoogle Scholar
  • 35 Benson AB, Burton Jr JR, Austin GL , et al. Differential effects of plasma and red blood cell transfusions on acute lung injury and infection risk following liver transplantation. Liver Transpl 2011; 17 (2) 149-158
    CrossrefPubMedGoogle Scholar
  • 36 Hébert PC, Wells G, Blajchman MA , et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian Critical Care Trials. N Eng J Med 1999; 340 (13) 409-417
    CrossrefPubMedGoogle Scholar
  • 37 Carson JL, Terrin ML, Noveck H , et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365 (26) 2453-2462
    CrossrefPubMedGoogle Scholar
  • 38 Villanueva C, Colomo A, Bosch A , et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368 (1) 11-21
    CrossrefPubMedGoogle Scholar
  • 39 Contandriopoulos A-P, Champagne F, Potvin L, Denis J-L, Boyle P. Savoir préparer une recherche: La définir, la structurer, la financer. Quebec, Canada: Les presses de l'Université de Montrtéal; 1990. : chap 2:49
    Google Scholar
  • 40 Blasi A, Beltran J, Pereira A , et al. An assessment of thromboelastometry to monitor blood coagulation and guide transfusion support in liver transplantation. Transfusion 2012; 52 (9) 1989-1998
    CrossrefPubMedGoogle Scholar
  • 41 Royston D, Bidstrup BP, Taylor KM, Sapsford RN. Effect of aprotinin on need for blood transfusion after repeat open-heart surgery. Lancet 1987; 2 (8571) 1289-1291
    PubMedGoogle Scholar
  • 42 Fergusson DA, Hébert PC, Mazer CD , et al; BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008; 358 (22) 2319-2331
    CrossrefPubMedGoogle Scholar
  • 43 Rana A, Petrowsky H, Hong JC , et al. Blood transfusion requirement during liver transplantation is an important risk factor for mortality. J Am Coll Surg 2013; 216 (5) 902-907
    CrossrefPubMedGoogle Scholar
  • 44 Chung HS, Jung DH, Park CS. Intraoperative predictors of short-term mortality in living donor liver transplantation due to acute liver failure. Transplant Proc 2013; 45 (1) 236-240
    CrossrefPubMedGoogle Scholar
  • 45 Li C, Wen TF, Yan LN , et al. Predictors of patient survival following living donor liver transplantation. Hepatobiliary Pancreat Dis Int 2011; 10 (3) 248-253
    CrossrefPubMedGoogle Scholar
  • 46 Dunn LK, Thiele RH, Ma JZ, Sawyer RG, Nemergut EC. Duration of red blood cell storage and outcomes following orthotopic liver transplantation. Liver Transpl 2012; 18 (4) 475-481
    CrossrefPubMedGoogle Scholar
  • 47 Matot I, Katz M, Pappo O , et al. Resuscitation with aged blood exacerbates liver injury in a hemorrhagic rat model. Crit Care Med 2013; 41 (3) 842-849
    CrossrefPubMedGoogle Scholar
  • 48 Nacoti M, Cazzaniga S, Lorusso F , et al. The impact of perioperative transfusion of blood products on survival after pediatric liver transplantation. Pediatr Transplant 2012; 16 (4) 357-366
    CrossrefPubMedGoogle Scholar
  • 49 Hatano E, Terajima H, Yabe S , et al. Hepatic artery thrombosis in living related liver transplantation. Transplantation 1997; 64 (10) 1443-1446
    CrossrefPubMedGoogle Scholar
  • 50 Glance LG, Dick AW, Mukamel DB , et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011; 114 (2) 283-292
    CrossrefPubMedGoogle Scholar
  • 51 Kaku R, Matsumi M, Ichiyama M , et al. Massive bleeding due to hyperfibrinolysis during living-related liver transplantation for terminal liver cirrhosis; report of two cases [in Japanese]. Masui 2003; 52 (11) 1195-1199
    PubMedGoogle Scholar
  • 52 Krzanicki D, Sugavanam A, Mallett S. Intraoperative hypercoagulability during liver transplantation as demonstrated by thromboelastography. Liver Transpl 2013; 19 (8) 852-861
    CrossrefPubMedGoogle Scholar
  • 53 Arshad F, Lisman T, Porte RJ. Hypercoagulability as a contributor to thrombotic complications in liver transplant recipient. Liver Int 2013; 33 (6) 820-827
    CrossrefPubMedGoogle Scholar
  • 54 Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion 2006; 46 (8) 1279-1285
    CrossrefPubMedGoogle Scholar
  • 55 Porte RJ. Coagulation and fibrinolysis in orthotopic liver transplantation: current views and insights. Semin Thromb Hemost 1993; 19 (3) 191-196
    Article in Thieme ConnectPubMedGoogle Scholar
  • 56 Kang Y. Transfusion based on clinical coagulation monitoring does reduce hemorrhage during liver transplantation. Liver Transpl Surg 1997; 3 (6) 655-659
    CrossrefPubMedGoogle Scholar
  • 57 Steib A, Gengenwin N, Freys G, Boudjema K, Levy S, Otteni JC. Predictive factors of hyperfibrinolytic activity during liver transplantation in cirrhotic patients. Br J Anaesth 1994; 73 (5) 645-648
    CrossrefPubMedGoogle Scholar
  • 58 Segal H, Cottam S, Potter D, Hunt BJ. Coagulation and fibrinolysis in primary biliary cirrhosis compared with other liver disease and during orthotopic liver transplantation. Hepatology 1997; 25 (3) 683-688
    CrossrefPubMedGoogle Scholar
  • 59 Kang YG, Martin DJ, Marquez J , et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64 (9) 888-896
    PubMedGoogle Scholar