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Pereira D, Liotta E, Mahmoud AA. The Use of Kcentra® in the Reversal of Coagulopathy of Chronic Liver Disease. J Pharm Pract 2017; 31:120-125. [DOI: 10.1177/0897190017696952] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We aim to describe our experience with the four-factor prothrombin complex concentrates (4F-PCC) Kcentra® at differing doses in patients with liver cirrhosis requiring emergent hemostasis in the setting of major or life-threatening bleeding. An automated query of patients who received Kcentra between January 2014 and March 2016 was performed. Patients who had clinically significant bleeding and received Kcentra for treatment of coagulopathy of chronic liver disease (CCLD) were included in the study. Baseline patient demographics, administration indication, pertinent laboratory values, and other reversal therapies were collected. Four patients met inclusion for analysis. One patient presented with hemopericardium, cardiac tamponade, and shock, and 3 patients presented with intracranial hemorrhage. Each patient experienced an improvement in international normalized ratio (INR) and at least a period of clinical hemostasis after Kcentra administration without complications referable to Kcentra. Kcentra may be a safe, rapid, and effective treatment option for hemorrhagic emergencies associated with CCLD. Further research is needed to determine the ideal monitoring and dosing regimen for use in CCLD.
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Affiliation(s)
- Deepika Pereira
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Eric Liotta
- Section of Neurocritical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Ahmed A. Mahmoud
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
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52
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Value of Preoperative Hemostasis Testing in Patients with Liver Disease for Perioperative Hemostatic Management. Anesthesiology 2017; 126:338-344. [DOI: 10.1097/aln.0000000000001467] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Preoperative hemostasis testing may have limited use in patients with liver disease, and an abnormal platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen level should not trigger prophylactic transfusion of blood product components.
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53
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The Rebalanced Hemostasis System in End-stage Liver Disease and Its Impact on Liver Transplantation. Int Anesthesiol Clin 2017; 55:107-120. [DOI: 10.1097/aia.0000000000000139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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54
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Plasma Transfusion in Patients With Cirrhosis in China: A Retrospective Multicenter Cohort Study. Transfus Med Rev 2016; 31:107-112. [PMID: 28063764 DOI: 10.1016/j.tmrv.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 12/19/2022]
Abstract
Patients with cirrhosis used to be associated with frequent use of blood components because of their complex disorder of hemostasis and bleeding complications. Recent findings have indicated that patients with cirrhosis have a state of "rebalanced" or even procoagulant hemostasis and have questioned the prophylactic use of plasma. To evaluate the current status of plasma use in patients with cirrhosis, we conducted a retrospective survey in 11 tertiary-care hospitals in China from September 1 to October 31, 2013. All patients admitted with cirrhosis during the study period were included in the study. The survey collected information including patients' diagnostic and demographic data, clinical course including bleeding complications and invasive procedures, laboratory results, and plasma transfusion data. Among 1595 patients with cirrhosis admitted to the 11 hospitals, 236 (14.8%) patients received 1 or more plasma transfusions during the study period. The number of plasma transfusions is defined as the number of transfusion orders. A total of 1037 plasma transfusions were administered to these patients, with a mean of 4.4 transfusions per transfused patient, ranging from 1 to 22 transfusions per transfused patient. Most plasma transfusions (760/1037; 73.3%) were given to patients without bleeding, for treatment of coagulopathy either without planned invasive procedures (70.4%) or before invasive procedures (2.9%). The median dose of plasma transfusion was 3.8 mL/kg. The rate of plasma transfusion of participating hospitals varied from 5.3% to 31.8%. It is encouraging to see that in one teaching hospital, 85.7% plasma transfusions were given to patients with bleeding indication, showing a promising sign in appropriate transfusion. Prophylaxis or empirical plasma transfusion is still a common problem in managing patients with liver cirrhosis. Wide variations are found in plasma transfusion practice among hospitals. Effective measures to control and reduce empirical correction of abnormal coagulation tests through transfusing plasma should be strengthened urgently.
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55
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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56
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Loftus TJ, Jordan JR, Croft CA, Smith RS, Efron PA, Moore FA, Mohr AM, Brakenridge SC. Emergent laparotomy and temporary abdominal closure for the cirrhotic patient. J Surg Res 2016; 210:108-114. [PMID: 28457316 DOI: 10.1016/j.jss.2016.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/11/2016] [Accepted: 11/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients. METHODS We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals. RESULTS At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients. CONCLUSIONS Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Janeen R Jordan
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Chasen A Croft
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - R Stephen Smith
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Philip A Efron
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Frederick A Moore
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida.
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57
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Newman JM, Schiltz NK, Mudd CD, Szubski CR, Klika AK, Barsoum WK. Impact of Cirrhosis on Resource Use and Inpatient Complications in Patients Undergoing Total Knee and Hip Arthroplasty. J Arthroplasty 2016; 31:2395-2401. [PMID: 27236746 PMCID: PMC5069119 DOI: 10.1016/j.arth.2016.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cirrhosis is a major cause of morbidity and mortality and is an important risk factor for complications in surgical patients. The purpose of this study was to investigate the association of cirrhosis with postoperative complications, length of stay (LOS), and costs among patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS Using the Nationwide Inpatient Sample between 2000 and 2011, we identified patients who had a primary TKA or primary THA. TKA patients were divided into 2 groups: (1) cirrhosis (n = 41,464) and (2) no cirrhosis (n = 5,721,297) and THA patients were divided into 2 groups: (1) cirrhosis (n = 27,401) and (2) no cirrhosis (n = 2,622,539). Patient demographics, comorbidities, perioperative complications, LOS, and incremental costs were analyzed. An additional subgroup analysis by cirrhosis etiology was performed. RESULTS Multivariable analysis revealed cirrhosis was associated with 1.55 (95% confidence interval: 1.47-1.63) times higher odds of any complication after TKA and 1.59 (1.50-1.69) higher odds after THA. Adjusted outcomes showed cirrhotic TKA patients had $1857 higher costs and 0.30 days longer LOS and THA cirrhotic patients had $1497 higher costs and 0.48 longer LOS. We found similar results for each cirrhosis subtype but alcohol-related had the highest resource use and complication rate. CONCLUSION Patients with cirrhosis who are undergoing TKA or THA are at a significantly increased risk for perioperative complications, increased LOS, and higher costs. The perioperative complications and costs were highest among patients with alcohol-related cirrhosis.
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Affiliation(s)
- Jared M. Newman
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Nicholas K. Schiltz
- Department of Epidemiology and Biostatistics, Case Western Reserve University, 2103 Cornell Rd. Cleveland, OH 44106
| | - Christopher D. Mudd
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Caleb R. Szubski
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Wael K. Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
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58
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Eilers H. Advances in anesthesia and critical care. Liver Transpl 2016; 22:20-24. [PMID: 27595667 DOI: 10.1002/lt.24632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/01/2016] [Accepted: 09/01/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Helge Eilers
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.
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60
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Brustia R, Granger B, Scatton O. An update on topical haemostatic agents in liver surgery: systematic review and meta analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:609-621. [PMID: 27580747 DOI: 10.1002/jhbp.389] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/29/2016] [Indexed: 12/31/2022]
Abstract
Mortality and morbidity in hepatic surgery are affected by blood loss and transfusion. Topical haemostatic agents (THA) are composed by a matrix and/or fibrin sealants, and their association known as "carrier-bound fibrin sealant" (CBFS): despite widely used for secondary haemostasis, the level of evidence remains low. To realize a meta-analysis on the results of CBFS on haemostasis and postoperative complications. Searches in PubMed, PubMed Central, Cochrane and Google Scholar using keywords: "topical_haemostasis" OR "haemostatic_agents" OR "sealant_patch" OR "fibrin_sealant" OR "collagen_sealant" AND "liver_surgery" OR "hepatic_surgery" OR "liver_transplantation". Randomized clinical trials, large retrospective cohort studies, case control studies evaluating THA on open/laparoscopic liver surgery and transplantation. From 1993 to 2016 were found 22 studies for qualitative synthesis and 13 for quantitative meta-analysis. The time to haemostasis was lower in the CBFS group (mean difference -2.33 min; P = 0.00001). The risk of receiving blood transfusion, developing collections and bile leak was not influenced by the use of CBFS (OR 0.75; P = 0.25), (OR 0.72; P = 0.52), (OR 0.74; P = 0.30) respectively. The use of CBFS in liver surgery significantly reduce the time to haemostasis, but does not decrease transfusion, postoperative collection and bile leak.
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Affiliation(s)
- Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.,Université Pierre et Marie Curie, Paris, France
| | - Benjamin Granger
- Department of Biostatistics, Public Health and Medical Information, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l' Hôpital, Paris, 75013, France. .,Université Pierre et Marie Curie, Paris, France.
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61
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Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease. J Vasc Interv Radiol 2016; 27:1665-1674. [PMID: 27595469 DOI: 10.1016/j.jvir.2016.05.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 05/25/2016] [Accepted: 05/31/2016] [Indexed: 12/14/2022] Open
Abstract
The coagulopathy of liver disease is distinctly different from therapeutic anticoagulation in a patient. Despite stable elevated standard clot-based coagulation assays, nearly all patients with stable chronic liver disease (CLD) have normal or increased clotting. Common unfamiliarity with the limitations of these assays in CLD may lead to inappropriate and sometimes harmful interventions, including blood product transfusions before a procedure. Knowledge of the distinct hemostatic alterations in CLD can allow identification of the small subset of patients with clinically significant coagulopathy who can benefit from hematologic optimization before invasive procedures.
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63
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Abstract
OBJECTIVE Determine factors that increase the risk of bleeding after liver biopsy. METHODS Retrospective review of radiology and clinical databases from Jan 2008 to Jun 2014 revealed 847 patients with liver biopsy. Of these, 154 (group I) had targeted biopsy of focal lesion and 142 (group 2) had random core biopsy for diffuse liver disease. The rest of the patients were excluded due to insufficient post-biopsy data. Data including pre-biopsy laboratory results, history of transfusion, and biopsy complications were recorded in the study cohort. After review of initial results, a "Risk Score" for bleeding was created using platelet count, INR, estimated glomerular filtration rate (eGFR), and suspicion of malignancy. Zero point was given for normal laboratory results or absence of malignancy. One point was given for mildly abnormal laboratory values or presence of malignancy. Severe biochemical abnormalities, e.g., INR > 2.0, eGFR < 30 mL/min, or platelet count ≤ 50 × 10(9)/L were given two points each. The "Risk Score" was made of adding individual points. RESULTS Of 847 patients queried by retrospective database search, 296 had adequate records for the period of 2 weeks prior to biopsy to 4 weeks after biopsy. The remaining patients had liver biopsy as outpatients and probably did not have bleeding complications but no electronic records were found to confirm this. 25 (8.4%) of 296 patients had post-biopsy bleeding, with incidences of 11.7% and 4.9% in groups 1 and 2 (p = 0.04). On logistic regression analysis, the only significant predictor of bleeding was the "Risk Score" (p = 0.01, odds ratio 4.6). There was substantial overlap in INR, and platelet count in bleeders vs. non-bleeders. Pre-biopsy fresh frozen plasma or platelet concentrate infusions did not reduce the risk of bleeding. CONCLUSION INR and platelet count are not an independent risk factors for post-biopsy bleeding. A "Risk Score" made up of individual risk factors was a better predictor of bleeding.
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Yip J, Bruno DA, Burmeister C, Kazimi M, Yoshida A, Abouljoud MS, Schnickel GT. Deep Vein Thrombosis and Pulmonary Embolism in Liver Transplant Patients: Risks and Prevention. Transplant Direct 2016; 2:e68. [PMID: 27500259 PMCID: PMC4946512 DOI: 10.1097/txd.0000000000000578] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/05/2016] [Indexed: 01/17/2023] Open
Abstract
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are surgical complications estimated to occur in 5% to 10% of patients. There are limited data regarding DVT/PE in the early postoperative period in liver transplant patients. The aim of this study is to determine risk factors that influence the incidence of DVT/PE and the effectiveness of prophylaxis.
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Affiliation(s)
- James Yip
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - David A Bruno
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Charlotte Burmeister
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Marwan Kazimi
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Marwan S Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Gabriel T Schnickel
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
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Nadim MK, Durand F, Kellum JA, Levitsky J, O'Leary JG, Karvellas CJ, Bajaj JS, Davenport A, Jalan R, Angeli P, Caldwell SH, Fernández J, Francoz C, Garcia-Tsao G, Ginès P, Ison MG, Kramer DJ, Mehta RL, Moreau R, Mulligan D, Olson JC, Pomfret EA, Senzolo M, Steadman RH, Subramanian RM, Vincent JL, Genyk YS. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. J Hepatol 2016; 64:717-35. [PMID: 26519602 DOI: 10.1016/j.jhep.2015.10.019] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/30/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Constantine J Karvellas
- Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, McGuire VA Medical Center, Richmond, VA, USA
| | - Andrew Davenport
- University College London Center for Nephrology, Royal Free Hospital, University College London Medical School, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Javier Fernández
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Centro d'investigación biomedical en red de enfermedades hepáticas y digestivas, Barcelona, Spain
| | - Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Centro d'investigación biomedical en red de enfermedades hepáticas y digestivas, Barcelona, Spain
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David J Kramer
- Aurora Critical Care Service, Aurora Health Care, Milwaukee, WI, USA
| | - Ravindra L Mehta
- Division of Nephrology, University of California San Diego, San Diego, CA, USA
| | - Richard Moreau
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - David Mulligan
- Section of Transplantation and Immunology, Department of Surgery, Yale-New Haven Hospital Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - Jody C Olson
- Division of Hepatology, University of Kansas Hospital, Kansas City, KS, USA
| | - Elizabeth A Pomfret
- Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Randolph H Steadman
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Ram M Subramanian
- Divisions of Gastroenterology and Pulmonary & Critical Care Medicine, Emory University Hospital, Atlanta, GA, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Yuri S Genyk
- Division of Hepatobiliary Surgery and Abdominal Organ Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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66
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Curnow J, Pasalic L, Favaloro EJ. Why Do Patients Bleed? Surg J (N Y) 2016; 2:e29-e43. [PMID: 28824979 PMCID: PMC5553458 DOI: 10.1055/s-0036-1579657] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/01/2016] [Indexed: 12/19/2022] Open
Abstract
Patients undergoing surgical procedures can bleed for a variety of reasons. Assuming that the surgical procedure has progressed well and that the surgeon can exclude surgical reasons for the unexpected bleeding, then the bleeding may be due to structural (anatomical) anomalies or disorders, recent drug intake, or disorders of hemostasis, which may be acquired or congenital. The current review aims to provide an overview of reasons that patients bleed in the perioperative setting, and it also provides guidance on how to screen for these conditions, through consideration of appropriate patient history and examination prior to surgical intervention, as well as guidance on investigating and managing the cause of unexpected bleeding.
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Affiliation(s)
- Jennifer Curnow
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia
| | - Leonardo Pasalic
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia.,Pathology West, NSW Health Pathology, Westmead, Australia
| | - Emmanuel J Favaloro
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia.,Pathology West, NSW Health Pathology, Westmead, Australia
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Yates SG, Gavva C, Agrawal D, Sarode R. How do we transfuse blood components in cirrhotic patients undergoing gastrointestinal procedures? Transfusion 2016; 56:791-8. [DOI: 10.1111/trf.13495] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 12/02/2015] [Accepted: 12/18/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Sean G. Yates
- Department of Pathology, Division of Transfusion Medicine and Hemostasis; University of Texas Southwestern Medical Center; Dallas Texas
| | - Chakri Gavva
- Department of Pathology, Division of Transfusion Medicine and Hemostasis; University of Texas Southwestern Medical Center; Dallas Texas
| | - Deepak Agrawal
- Department of Internal Medicine, Division of Division of Digestive and Liver Diseases; University of Texas Southwestern Medical Center; Dallas Texas
| | - Ravi Sarode
- Department of Pathology, Division of Transfusion Medicine and Hemostasis; University of Texas Southwestern Medical Center; Dallas Texas
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Nacoti M, Corbella D, Fazzi F, Rapido F, Bonanomi E. Coagulopathy and transfusion therapy in pediatric liver transplantation. World J Gastroenterol 2016; 22:2005-23. [PMID: 26877606 PMCID: PMC4726674 DOI: 10.3748/wjg.v22.i6.2005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 11/23/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently lacking regarding the use of anti-aggregation/anticoagulation therapies and how to best monitor for thrombosis in the early postoperative period in pediatric patients. Therefore, further studies are necessary to elucidate the interaction between the development of the coagulation system and cirrhosis in children. Moreover, strategies to optimize blood transfusion and anticoagulation must be tested specifically in pediatric patients. In conclusion, data from the adult world can be translated with difficulty into the pediatric field as indication for transplantation, baseline pathologies and levels of pro- and anticoagulation factors are not comparable between the two populations.
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69
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Bolton-Maggs PHB, New HV, Tinegate H. Use of and reactions to fresh frozen plasma in the UK. ACTA ACUST UNITED AC 2016. [DOI: 10.1111/voxs.12190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
| | - H. V. New
- Department of Paediatrics; Imperial College Healthcare Trust; London UK
| | - H. Tinegate
- National Blood Service; Newcastle upon Tyne UK
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70
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Hartmann M, Szalai C, Saner FH. Hemostasis in liver transplantation: Pathophysiology, monitoring, and treatment. World J Gastroenterol 2016; 22:1541-50. [PMID: 26819521 PMCID: PMC4721987 DOI: 10.3748/wjg.v22.i4.1541] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/29/2015] [Accepted: 11/13/2015] [Indexed: 02/06/2023] Open
Abstract
Recent findings in the pathophysiology and monitoring of hemostasis in patients with end stage liver disease have major impact on coagulation management during liver transplantation. There is increasing evidence, that the changes in both coagulation factors and platelet count regularly observed in patients with liver cirrhosis cannot be interpreted as a reliable indicator of diffuse bleeding risk. Instead, a differentiated view on hemostasis has led to the concept of a rebalanced coagulation system: While it is important to recognize that procoagulant factors are reduced in liver cirrhosis, it is also evident that synthesis of anticoagulant factors and fibrinolytic proteins produced in the liver is also diminished. Similarly, the decreased platelet count may be counterbalanced by increased platelet aggregability caused by highly active von Willebrand multimeres. The coagulation system is therefor stated to be rebalanced. While under normal "unstressed" conditions diffuse bleeding is rarely observed, however both diffuse bleeding or thrombus formation may occur when compensation mechanisms are exhausted. While most patients presenting for liver transplantation have severe cirrhosis, liver function and thus production of pro- and anticoagulant factors can be preserved especially in cholestatic liver disease. During liver transplantation, profound changes in the hemostasis system can occur. Surgical bleeding can lead to diffuse bleeding as coagulation factors and platelets are already reduced. Ischemia and tissue trauma can lead to alterations of hemostasis comparable to trauma induced coagulopathy. A further common disturbance often starting with the reperfusion of the transplanted organ is hyperfibrinolysis which can eventually precipitate complete consumption of fibrinogen and an endogenous heparinization by glycocalyx shedding. Moreover, thrombotic events in liver transplantations are not uncommon and contribute to increased mortality. Besides conventional laboratory methods, bed-side monitoring of hemostasis (e.g., thrombelastography, thrombelastometry) is often used during liver transplantation to rapidly diagnose decreases in fibrinogen and platelet count as well as hyperfibrinolysis and to guide treatment with blood products, factor concentrates, and antifibrinolytics. There is also evidence which suggests when algorithms based on bed-side hemostasis monitoring are used a reduction of blood loss, blood product use, and eventual mortality are possible. Notably, the bed-side monitoring of anticoagulant pathways and the thrombotic risk is not possible at time and thus a cautious and restrictive use of blood products is recommended.
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71
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Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5:165-182. [PMID: 26722645 PMCID: PMC4689928 DOI: 10.5500/wjt.v5.i4.165] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.
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Usefulness of thromboelastometry in predicting the risk of bleeding in cirrhotics who undergo invasive procedures. Eur J Gastroenterol Hepatol 2015. [PMID: 26225869 DOI: 10.1097/meg.0000000000000442] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The management of patients with liver cirrhosis undergoing invasive procedures is controversial and haemostasis assessment using routine laboratory is inappropriate. We evaluated the following: (a) the ability of thromboelastometry to predict the risk of bleeding in cirrhotic patients undergoing invasive procedures and enable a decision on the prophylactic transfusional strategy; (b) the contribution of platelet adhesion and aggregation tests in the assessment of haemostasis. PATIENTS AND METHODS Seventeen cirrhotic patients undergoing invasive procedures were analyzed retrospectively (training set). To obtain preliminary data, an observational study was carried out in 58 patients (test set). All 75 patients were evaluated by thromboelastometry. Platelet adhesion and aggregation were evaluated in 16 patients using Multiplate, PFA-100 and Light Transmission Aggregometry. Factor VIII was dosed in all patients of the test set. RESULTS In the training set, thromboelastometry confirmed the haemostatic assessment shown by the conventional test only in 6/17 (35%) patients. In the test set, thromboelastometry identified all patients who had a bleeding event. In patients with a high risk of bleeding, the use of thromboelastometry was cost-effective, reducing the platelet infusions by 64%. Platelet adhesion/aggregation abnormalities were observed in 15/16 (94%) patients, but bleeding events occurred only in 2/15 (13%) patients. CONCLUSION Thromboelastometry appears to be useful to screen cirrhotic patients undergoing invasive procedures to identify the risk of bleeding and to optimize the transfusional strategy. Adhesion/aggregation tests are not useful in identifying patients at risk of bleeding and their application is not cost-effective.
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73
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Is There a Role for Desmopressin in Liver Transplantation? A Case Report. Transplant Proc 2015; 47:2782-5. [DOI: 10.1016/j.transproceed.2015.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/17/2015] [Indexed: 12/19/2022]
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De Pietri L, Mocchegiani F, Leuzzi C, Montalti R, Vivarelli M, Agnoletti V. Transoesophageal echocardiography during liver transplantation. World J Hepatol 2015; 7:2432-2448. [PMID: 26483865 PMCID: PMC4606199 DOI: 10.4254/wjh.v7.i23.2432] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/22/2015] [Accepted: 09/09/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver transplant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the procedures as a result of both the disease process and the surgery. Transoesophageal echocardiography (TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. Moreover, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.
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Abstract
Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features. A new diagnostic score, the Chronic Liver Failure Consortium (CLIF-C) organ failure score, has been developed for classification and prognostic assessment of patients with acute-on-chronic liver failure. Disease can be reversed in many patients, and thus clinical management focuses upon the identification and treatment of the precipitant while providing multiorgan-supportive care that addresses the complex pattern of physiological disturbance in critically ill patients with liver disease. Liver transplantation is a highly effective intervention in some specific cases, but recipient identification, organ availability, timing of transplantation, and high resource use are barriers to more widespread application. Recognition of acute-on-chronic liver failure as a clinically and pathophysiologically distinct syndrome with defined diagnostic and prognostic criteria will help to encourage the development of new management pathways and interventions to address the unacceptably high mortality.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, King's College Hospital, London, UK.
| | - Rajiv Jalan
- Liver Failure Group, Division of Medicine, University College London, London, UK; Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Alberto Quaglia
- Histopathology Section, Institute of Liver Studies, King's College Hospital, London, UK
| | - Kenneth Simpson
- Department of Hepatology, University of Edinburgh, Edinburgh, UK
| | - Julia Wendon
- Liver Intensive Therapy Unit, King's College Hospital, London, UK
| | - Andrew Burroughs
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
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76
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Blasi A. Coagulopathy in liver disease: Lack of an assessment tool. World J Gastroenterol 2015; 21:10062-10071. [PMID: 26401071 PMCID: PMC4572787 DOI: 10.3748/wjg.v21.i35.10062] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/29/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
There is a discrepancy between the information from clotting tests which have routinely been used in clinical practice and evidence regarding thrombotic and bleeding events in patients with liver disease. This discrepancy leads us to rely on other variables which have been shown to be involved in haemostasis in these patients and/or to extrapolate the behaviour of these patients to other settings in order to decide the best clinical approach. The aims of the present review are as follows: (1) to present the information provided by clotting tests in cirrhotic patients; (2) to present the factors that may influence clotting in these patients; (3) to review the clinical evidence; and (4) to put forward a clinical approach based on the first 3 points.
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77
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Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg 2015; 2:43. [PMID: 26389122 PMCID: PMC4558465 DOI: 10.3389/fsurg.2015.00043] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/17/2015] [Indexed: 12/18/2022] Open
Abstract
Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University , Townsville, QLD , Australia
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78
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Abstract
Due to progressive advances in surgical techniques, immunosuppressive therapies, and supportive care, outcomes from both solid organ transplantation and hematopoietic stem cell transplantation continue to improve. Thrombosis remains a challenging management issue in this context, with implications for both graft survival and long-term quality of life. Unfortunately, there remains a general paucity of pediatric-specific data regarding thrombosis incidence, risk stratification, and the safety or efficacy of preventative strategies with which to guide treatment algorithms. This review summarizes the available evidence and rationale underlying the spectrum of current practices aimed at preventing thrombosis in the transplant recipient, with a particular focus on risk factors, pathophysiology, and described antithrombotic regimens.
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Affiliation(s)
- J D Robertson
- Haematology Service, Division of Medicine, Lady Cilento Children's Hospital, Brisbane, Qld, Australia
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79
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Preserved clot formation detected by the Thrombodynamics analyzer in patients with cirrhosis. Thromb Res 2015; 135:1012-6. [DOI: 10.1016/j.thromres.2015.02.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/23/2015] [Accepted: 02/19/2015] [Indexed: 12/19/2022]
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80
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Akamatsu N, Sugawara Y, Nakazawa A, Nishioka Y, Kaneko J, Aoki T, Sakamoto Y, Hasegawa K, Kokudo N. Hemostatic status in liver transplantation: association between preoperative procoagulants/anticoagulants and postoperative hemorrhaging/thrombosis. Liver Transpl 2015; 21:258-65. [PMID: 25370801 DOI: 10.1002/lt.24038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/07/2014] [Accepted: 10/12/2014] [Indexed: 12/17/2022]
Abstract
The delicate rebalanced hemostatic status of liver transplant recipients may lead to both hemorrhagic and thrombotic tendencies in this population. The aim of this study was to investigate the association between pretransplant procoagulants/anticoagulants and posttransplant bleeding and thrombosis among living donor liver transplant recipients. The study subjects were 403 consecutive recipients with chronic liver disease. Perioperative variables, including preoperative values for procoagulants and anticoagulants, were assessed to determine their association with posttransplant hemorrhaging and thrombosis. There were 35 hemorrhagic complications (9%) and 21 thrombotic complications (5%). In logistic regression analyses, a higher Model for End-Stage Liver Disease score (P = 0.01) and a lower fibrinogen value (P < 0.001) were independently associated with hemorrhaging, whereas only a lower protein C value (P < 0.001) was independently associated with thrombosis. In a receiver operating characteristic analysis, a low preoperative protein C value (with the most accurate cutoff value being 25%) was a reliable predictor of thrombotic complications after liver transplantation (area under the curve = 0.921, P < 0.001, sensitivity = 0.9, specificity = 0.8). In conclusion, the decreases in both procoagulants and anticoagulants in liver transplant recipients may additively result in a delicate hemostatic balance and predispose patients to both hemorrhagic and thrombotic complications. A lower preoperative protein C value (<25%) was demonstrated to be a significant and reliable predictor of postoperative thrombotic complications in liver transplant recipients.
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Affiliation(s)
- Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Pohlman TH, Walsh M, Aversa J, Hutchison EM, Olsen KP, Lawrence Reed R. Damage control resuscitation. Blood Rev 2015; 29:251-62. [PMID: 25631636 DOI: 10.1016/j.blre.2014.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 11/05/2014] [Accepted: 12/16/2014] [Indexed: 02/07/2023]
Abstract
The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding.
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Affiliation(s)
- Timothy H Pohlman
- Department of Surgery, Methodist Hospital Indiana University, Indianapolis, IN, USA.
| | - Mark Walsh
- Memorial Hospital Trauma Center, Indiana University, South Bend, IN, USA
| | - John Aversa
- Memorial Hospital Trauma Center, Indiana University, South Bend, IN, USA
| | - Emily M Hutchison
- Department Pharmacy, Methodist Hospital, Indiana University, Indianapolis, IN, USA
| | - Kristen P Olsen
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN, USA
| | - R Lawrence Reed
- Department of Surgery, Methodist Hospital Indiana University, Indianapolis, IN, USA
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82
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Abstract
In patients with cirrhosis, routine laboratory tests for primary hemostasis and coagulation usually show anomalies that are associated with excess bleeding in other settings, in particular low platelet counts and prolonged prothrombin time. However, under conditions similar to those in vivo, primary hemostasis and thrombin production do not appear to be decreased in patients with cirrhosis, particularly when the platelet count is above 75,000/μl. Furthermore, there is laboratory and epidemiological evidence of a mild procoagulant and prothrombotic state in patients with cirrhosis. Bleeding is mainly because of portal hypertension rather than defective hemostasis. There is some evidence that anticoagulation therapy is not associated with an excess of severe bleeding and that it could improve the outcome in patients without portal vein thrombosis. At present, there is no clear evidence that portal vein thrombosis is responsible for the progression of liver disease and that anticoagulation therapy would improve the outcome of patients with portal vein thrombosis.
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Affiliation(s)
- Dominique-C Valla
- DHU UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy-la-Garenne, France; INSERM, U1149, CRI, Université Paris-Diderot, Paris, France
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83
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Yamashita YI, Bekki Y, Imai D, Ikegami T, Yoshizumi T, Ikeda T, Kawanaka H, Nishie A, Shirabe K, Maehara Y. Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer. Thromb Res 2014; 134:826-31. [PMID: 25156238 DOI: 10.1016/j.thromres.2014.07.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/05/2014] [Accepted: 07/28/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUNDS Enoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery. STUDY DESIGN A retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n=228) and an enoxaparin (+) group (n=53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared. RESULTS In the enoxaparin (+) group, the patients' age (65 vs. 69 years; p=0.01) and BMI (22.9 vs. 24.4; p<0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p=0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p=0.04). The independent risk factors for PVT were an operation time ≥ 300 minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49). CONCLUSIONS Postoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.
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Affiliation(s)
- Yo-Ichi Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Yuki Bekki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Daisuke Imai
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tetsuo Ikeda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hirofumi Kawanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Akihiro Nishie
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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