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Pamulapati S, Conroy M, Madireddy S, Kamaraju S, Cortina C, Moore H, Hartmann J. Applications of Viscoelastic Testing in Breast Cancer Patients: A Systematic Review Focusing on Hypercoagulability and Free Flap Thrombosis. Semin Thromb Hemost 2024; 50:413-422. [PMID: 37327882 DOI: 10.1055/s-0043-1769937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Viscoelastic testing is a clinically available method to assess hypercoagulability. This systematic review aims to provide a comprehensive overview of the existing literature and the potential use of such testing in patients with breast cancer. A systematic literature search for studies investigating the application of viscoelastic testing for patients with breast cancer was conducted. Studies were included as long as they were original, peer-reviewed, and in the English language. Studies were excluded if they were review articles, did not include breast cancer patients, or if the full text was unavailable. This review identified 10 articles that met the inclusion criteria. Two of the studies utilized rotational thromboelastometry, and an additional four studies used thromboelastography, to assess hypercoagulability in patients with breast cancer. Three of the identified articles discussed the use of thromboelastometry in free flap breast reconstruction for patients with breast cancer. One study was a retrospective chart review looking at thromboelastography and microsurgical breast reconstruction. Current literature regarding the application of viscoelastic testing in breast cancer and free flap breast reconstruction is limited, with no randomized trials thus far. However, some studies suggest that there may be potential utility in viscoelastic testing to assess risk for thromboembolism in breast cancer patients, and future research in this area is warranted.
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Affiliation(s)
| | | | | | - Sailaja Kamaraju
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Chandler Cortina
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hunter Moore
- Division of Surgery-Transplant, University of Colorado School of Medicine, Aurora, Colorado
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2
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Pérez-Calatayud AA, Hofmann A, Pérez-Ferrer A, Escorza-Molina C, Torres-Pérez B, Zaccarias-Ezzat JR, Sanchez-Cedillo A, Manuel Paez-Zayas V, Carrillo-Esper R, Görlinger K. Patient Blood Management in Liver Transplant—A Concise Review. Biomedicines 2023; 11:biomedicines11041093. [PMID: 37189710 DOI: 10.3390/biomedicines11041093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/07/2023] Open
Abstract
Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.
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Affiliation(s)
| | - Axel Hofmann
- Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth 6907, WA, Australia
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, 8057 Zurich, Switzerland
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, 28700 San Sebastián de los Reyes, Spain
- Department of Anesthesiology, European University of Madrid, 28702 Madrid, Spain
| | - Carla Escorza-Molina
- Departmen of Anesthesiology, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Bettina Torres-Pérez
- Department of Anesthesiology, Pediatric Transplant, Centro Medico de Occidente, Instituto Mexicano del Seguro Social, Guadalajara 44329, Mexico
| | | | - Aczel Sanchez-Cedillo
- Transplant Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Victor Manuel Paez-Zayas
- Gastroenterology Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | | | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45131 Essen, Germany
- TEM Innovations GmbH, 81829 Munich, Germany
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3
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Yassen KA, Refaat EK, Helal SM, Metwally AA, Youssef SD, Görlinger K. Detection and quantification of perioperative heparin-like effects by rotational thromboelastometry in living-donor liver transplant recipients: A prospective observational study. J Anaesthesiol Clin Pharmacol 2023; 39:285-291. [PMID: 37564856 PMCID: PMC10410046 DOI: 10.4103/joacp.joacp_521_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 08/12/2023] Open
Abstract
Background and Aims Heparin-like effects (HLEs) can affect hemostasis during liver transplantation. The aim of this study was to assess the perioperative incidence and severity of HLE with rotational thromboelastometry (ROTEM) and activated partial thromboplastin time (aPTT). Material and Methods ROTEM and aPTT were measured intraoperatively and on postoperative days (POD) 1, 3, and 7. HLE was identified if ROTEM INTEM/HEPTEM CT-ratio was >1.25 and severe forms of HLE when ratio was ≥2. Based on aPTT, HLE was defined when aPTT ratio was >1.25 (patient aPTT/control aPTT). Results Thirty-eight recipients were included. Variable degrees of HLE were detected by aPTT-ratio and INTEM/HEPTEM CT ratio. No significant correlation existed between both ratios. Based on INTEM/HEPTEM CT ratio, HLE was detected in 7/38 during anhepatic phase, 19/38 post-reperfusion, 10/38 on POD1, 4/38 on POD3, and 0/38 on POD7. Four cases of severe HLE were identified by INTEM/HEPTEM CT ratio only in the anhepatic phase. Postoperative infusion of unfractionated heparin led to mild-moderate HLE on POD1 and 3 as evident by both tests. Red blood cell and plasma transfusion were higher with severe HLE (1350 ± 191 ml and 3558 ± 1407 ml). Composite adverse outcome of any complication or death within 3 months for patients without HLE, mild-moderate HLE, and severe HLE as detected by ROTEM was 27.8%, 42.9%, and 66.7%, respectively. Conclusion INTEM/HEPTEM CT ratio was able to detect and quantify HLE as aPTT ratio. The ability of the INTEM/HEPTEM CT ratio to identify severe HLE earlier in the anhepatic phase needs to be studied in a larger population. HLE is self-limiting, but when identified in a severe form, it is associated with worse outcome.
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Affiliation(s)
- Khaled A. Yassen
- Anaesthesia Department, National Liver Institute, Menoufia University, Shebeen El Kom City, Egypt
- Anesthesia Unit/Surgery Department, College of Medicine, King Faisal University, Alhasa, Saudi Arabia
| | - Emad K. Refaat
- Anaesthesia Department, National Liver Institute, Menoufia University, Shebeen El Kom City, Egypt
| | - Safaa M. Helal
- Anaesthesia Departments, Faculty of Medicine, Menoufia University, Shebeen El Kom City, Egypt
| | - Ahmed A. Metwally
- Anaesthesia Departments, Faculty of Medicine, Menoufia University, Shebeen El Kom City, Egypt
| | - Sherin D. Youssef
- Anaesthesia Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Klaus Görlinger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany; and Tem Innovations GmbH, Munich, Germany
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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5
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Stewart E, Nydam TL, Hendrickse A, Pomposelli JJ, Pomfret EA, Moore HB. Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation. Semin Thromb Hemost 2023; 49:119-133. [PMID: 36318962 PMCID: PMC10366939 DOI: 10.1055/s-0042-1758058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.
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Affiliation(s)
- Erin Stewart
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Adrian Hendrickse
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - James J. Pomposelli
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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6
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Hypercoagulability in critically ill patients with COVID 19, an observational prospective study. PLoS One 2022; 17:e0277544. [PMID: 36417476 PMCID: PMC9683576 DOI: 10.1371/journal.pone.0277544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/30/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE COVID 19 is often associated with hypercoagulability and thromboembolic (TE) events. The aim of this study was to assess the characteristics of hypercoagulability and its relationship with new-onset TE events and the composite outcome of need for intubation and/or death in intensive care unit (ICU) patients admitted for COVID. DESIGN Prospective observational study. SETTING Monocentric, intensive care, University Hospital of Clermont Ferrand, France. PATIENTS Patients admitted to intensive care from January 2020 to May 2021 for COVID-19 pneumonia. INTERVENTIONS Standard hemostatic tests and rotational thromboelastometry (ROTEM) were performed on admission and on day 4. Hypercoagulability was defined by at least one of the following criteria: D-dimers > 3000 μg/dL, fibrinogen > 8 g/L, EXTEM CFT below the normal range, EXTEM A5, MCF, Li 60 above the normal range, and EXTEM G-score ((5000 x MCF) / (100-MCF)) ≥ 11 dyne/cm2. MEASUREMENTS AND MAIN RESULTS Of the 133 patients included, 17 (12.7%) developed new-onset TE events, and 59 (44.3%) required intubation and/or died in the ICU. ROTEM was performed in 133 patients on day 1 and in 67 on day 4. Hypercoagulability was present on day 1 in 115 (86.4%) patients. None of the hypercoagulability indices were associated with subsequent new-onset TE events on days 1 and 4 nor with the need for intubation and/or ICU death. Hyperfibrinogenemia > 8g/dL, higher D-dimers and higher EXTEM Li 60 on day 4 were predictive of need for intubation and/or of ICU death. CONCLUSIONS Our study confirmed that most COVID-19 ICU patients have hypercoagulability on admission and almost all on day 4. Hyperfibrinogenemia or fibrinolysis shutdown on day 4 were associated with unfavorable outcome.
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Sakai T, Ko JS, Crouch CE, Kumar S, Little MB, Chae MS, Ganoza A, Gómez-Salinas L, Humar A, Kim SH, Koo BN, Rodriguez G, Sirianni J, Smith NK, Song JG, Ullah A, Hendrickse A. Perioperative management of adult living donor liver transplantation: Part 1 - recipients. Clin Transplant 2022; 36:e14667. [PMID: 35435293 DOI: 10.1111/ctr.14667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/06/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022]
Abstract
Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | - Justin Sangwook Ko
- Department of Anesthesiology & Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cara E Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sathish Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael B Little
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, USA
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Luis Gómez-Salinas
- Department of Anesthesiology and Pain Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Abhi Humar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sang Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gonzalo Rodriguez
- Department of Surgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joel Sirianni
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Aisha Ullah
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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8
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Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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9
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Craig-Schapiro R, Banc-Husu AM, Taylor SA, Bercovitz RS, Lemoine CP, Superina RA. Bivalirudin for the prevention of hepatic artery thrombosis in pediatric liver transplantation. Pediatr Transplant 2021; 25:e14068. [PMID: 34258834 DOI: 10.1111/petr.14068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early hepatic artery thrombosis (HAT) after liver transplantation is a serious complication that frequently results in graft loss and the need for retransplantation. Although studies have reported on various operative and endovascular treatment approaches, pharmacologic strategies for the prevention or management of HAT are not well defined. Patients with blood clotting disorders, those with a contraindication to heparin, and those who have previously developed HAT represent unique challenges in management. METHODS We present the case of a 9-month-old male with a hypercoagulable state who developed early HAT after two liver transplants, despite the use of postoperative therapeutic heparin infusion. RESULTS AND CONCLUSION The patient successfully underwent a third liver transplant using intraoperative and postoperative bivalirudin infusion, a direct thrombin inhibitor. Rotational thromboelastometry (ROTEM) was used to guide anticoagulation and blood product administration in the perioperative period. At 1.5 years post-transplant, the patient has good graft function with patent hepatic vasculature. This case demonstrates the innovative use of bivalirudin anticoagulant therapy and viscoelastic methodologies to improve outcomes in hypercoagulable liver transplant recipients.
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Affiliation(s)
- Rebecca Craig-Schapiro
- Division of Transplant Surgery, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sarah A Taylor
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachel S Bercovitz
- Division of Hematology and Oncology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Caroline P Lemoine
- Division of Transplant Surgery, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Riccardo A Superina
- Division of Transplant Surgery, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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10
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Szabó G, Antal-Szalmás P, Kerényi A, Pénzes K, Bécsi B, Kappelmayer J. Laboratory Approaches to Test the Function of Antiphospholipid Antibodies. Semin Thromb Hemost 2021; 48:132-144. [PMID: 34261151 DOI: 10.1055/s-0041-1730357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder caused by the presence of aPLs (antiphospholipid antibodies, i.e., anti-β2-glycoprotein I and anti-cardiolipin). Everyday practice in terms of laboratory diagnostics of APS includes determination of aPLs and well-known functional assays assessing for lupus anticoagulant (LA), in turn using various tests. According to recent guidelines, the recommended method for LA identification or exclusion is based on the Russell Viper Venom test and a sensitive activated partial thromboplastin time assay. Despite the fact that LA can be quantified in laboratory practice in this way, LA is still used as a binary parameter that is just one of the risk factors of thrombosis in APS. As of today, there are no other functional assays to routinely assess the risk of thrombosis in APS. It is well-known that APS patients display a wide range of clinical outcomes although they may express very similar laboratory findings. One way to solve this dilemma, could be if antibodies could be further delineated using more advanced functional tests. Therefore, we review the diagnostic approaches to test the function of aPLs. We further discuss how thrombin generation assays, and rotational thromboelastometry tests can be influenced by LA, and how experimental methods, such as flow cytometric platelet activation, surface plasmon resonance, or nano differential scanning fluorimetry can bring us closer to the puzzling interaction of aPLs with platelets as well as with their soluble protein ligand. These novel approaches may eventually enable better characterization of aPL, and also provide a better linkage to APS pathophysiology.
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Affiliation(s)
- Gábor Szabó
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Thrombosis, Haemostasis and Vascular Biology Programme, Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Antal-Szalmás
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Adrienne Kerényi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Krisztina Pénzes
- Division of Medical Laboratory Sciences, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Bálint Bécsi
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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11
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Mpaili E, Tsilimigras DI, Moris D, Sigala F, Frank SM, Hartmann J, Pawlik TM. Utility of viscoelastic coagulation testing in liver surgery: a systematic review. HPB (Oxford) 2021; 23:331-343. [PMID: 33229277 DOI: 10.1016/j.hpb.2020.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The objective of the current study was to summarize and evaluate all published evidence regarding viscoelastic testing in the field of liver surgery. METHODS A systematic search of the literature was performed using Medline/PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases. The following keywords were used:"Thromboelastography", "Thromboelastometry", "Viscoelastic tests OR testing", "Sonoclot Devices", "Point-of-care tests OR testing", "Coagulation OR Haemostasis OR Hemostasis", "Liver OR Hepatic Surgery", "Cirrhosis." RESULTS A total of 12 studies analyzing 348 patients who underwent viscoelastic testing of coagulation during liver surgery for benign or malignant diseases were included; 7 (58.3%) studies reported on the use of thromboelastography (TEG), and 5 (41.7%) reported on rotational thromboelastometry (ROTEM). Viscoelastic testing (TEG and ROTEM) identified normo-, hyper- and hypo-coagulable status in 77% (n = 268/348), 18.4% (n = 64/348), and 4.6% (n = 16/348) of patients, respectively. In contrast, conventional coagulation tests indicated normo-coagulability in 111 patients (34.2% out of 325) and hypo-coagulability in 214 (65.8% out of 325) patients following liver resection. No patient (0% out of 291) experienced postoperative hemorrhage, whereas 5.8% (n = 17/291) experienced postoperative thromboembolic events. CONCLUSIONS Global viscoelastic testing may be a reasonable adjunct to conventional coagulation testing to provide a more robust assessment of the coagulation status of patients undergoing liver surgery.
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Affiliation(s)
- Eustratia Mpaili
- Department of Surgery, Laikon University Hospital, University of Athens, Athens, Greece
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fragiska Sigala
- First Department of Surgery, Hippocration Hospital, University of Athens, Athens, Greece
| | - Steven M Frank
- Johns Hopkins Health System Blood Management Program, Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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12
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Wilke TJ, Fremming BA, Brown BA, Markin NW, Kassel CA. 2020 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2021; 36:1449-1457. [PMID: 33653578 PMCID: PMC7865096 DOI: 10.1053/j.jvca.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/13/2022]
Abstract
The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.
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Affiliation(s)
- Trevor J Wilke
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Bradley A Fremming
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Brittany A Brown
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Nicholas W Markin
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Cale A Kassel
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
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13
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Görlinger K, Almutawah H, Almutawaa F, Alwabari M, Alsultan Z, Almajed J, Alwabari M, Alsultan M, Shahwar D, Yassen KA. The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review. Korean J Anesthesiol 2021; 74:91-102. [PMID: 33440114 PMCID: PMC8024216 DOI: 10.4097/kja.21006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 02/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently recognized as a global health crisis. This viral infection is frequently associated with hypercoagulability, with a high incidence of thromboembolic complications that can be fatal. In many situations, the standard coagulation tests (SCT) fail to detect this state of hypercoagulability in patients with COVID-19 since clotting times are either not or only mildly affected. The role of viscoelastic tests such as rotational thromboelastometry (ROTEM®) during this pandemic is explored in this review. COVID-19-associated coagulopathy, as measured using the rotational thromboelastometry parameters, can vary from hypercoagulability due to increased fibrin polymerization and decreased fibrinolysis to bleeding from hypocoagulability. The use of a multimodal diagnostic and monitoring approach, including both rotational thromboelastometry and SCT, such as plasma fibrinogen and D-dimer concentrations, is recommended. Rotational thromboelastometry provides comprehensive information about the full coagulation status of each patient and detects individual variations. Since COVID-19-associated coagulopathy is a very dynamic process, the phenotype can change during the course of infection and in response to anticoagulation therapy. Data from published literature provide evidence that the combination of rotational thromboelastometry and SCT analysis is helpful in detecting hemostasis issues, guiding anticoagulant therapy, and improving outcomes in COVID-19 patients. However, more research is needed to develop evidence-based guidelines and protocols.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Hawra Almutawah
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Fatimah Almutawaa
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Zahra Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Jumanah Almajed
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Mahmoud Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Duri Shahwar
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Khaled Ahmed Yassen
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
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14
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Słomka A, Kowalewski M, Żekanowska E. Hemostasis in Coronavirus Disease 2019-Lesson from Viscoelastic Methods: A Systematic Review. Thromb Haemost 2021; 121:1181-1192. [PMID: 33401332 DOI: 10.1055/a-1346-3178] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemostatic unbalance is often observed in patients with coronavirus disease 2019 (COVID-19), and patients with severe disease are at high risk of developing thromboembolic complications. Viscoelastic methods (VEMs), including thrombelastography (TEG) and thromboelastometry (TEM), provide data on the nature of hemostatic disturbance. In this systematic review, we assessed the performance of TEG and TEM in the assessment of blood coagulation and fibrinolysis in patients with COVID-19. PubMed, Scopus, Web of Science Core Collection, medRxiv, and bioRxiv were systematically searched for clinical studies evaluating TEG and/or TEM variables in COVID-19 individuals. Ten studies, with a total of 389 COVID-19 patients, were included, and VEMs were performed in 292 of these patients. Most patients (90%) presented severe COVID-19 and required mechanical ventilation. TEG and TEM variables showed that these patients displayed hypercoagulability and fibrinolysis shutdown, despite the use of appropriate thromboprophylaxis. However, the mechanism underlying these phenomena and their clinical significance in COVID-19 patients who developed thrombosis are still not clear. Further studies are warranted if VEMs might help to identify those at highest risk of thrombotic events and who therefore may derive the greatest benefit from antithrombotic therapy.
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Affiliation(s)
- Artur Słomka
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland.,Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiothoracic Research Centre, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum Bydgoszcz, Poland
| | - Ewa Żekanowska
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum Bydgoszcz, Poland
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15
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Sakai T. Viscoelastic testing in liver transplantation. Transfusion 2020; 60 Suppl 6:S61-S69. [PMID: 33089935 DOI: 10.1111/trf.16077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 01/24/2023]
Abstract
Despite the lack of large randomized clinical studies, viscoelastic tests (VETs) have been a critical armamentarium for hemostatic control in liver transplantation (LT) since the 1960s. Many transplant institutions have adopted VETs in their clinical practice. Several small-size randomized clinical trials on LT patients have suggested that VET-guided hemostatic treatment algorithms have led to decreased indications for and amounts of transfused blood products, especially fresh-frozen plasma, compared to standard laboratory-based hemostatic management. VETs have also been reported to offer insight into the diagnosis and prediction of LT patients' development of hypercoagulability-related morbidity and mortality. There is still a need for VET device-specific hemostatic algorithms in LT, and clinicians must take into account the tendency to underestimate the coagulation capacity of VETs in patients with end-stage liver disease where hemostasis is rebalanced.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, Pennsylvania, USA
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16
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Kong R, Hutchinson N, Görlinger K. Hyper- and hypocoagulability in COVID-19 as assessed by thromboelastometry -two case reports. Korean J Anesthesiol 2020; 74:350-354. [PMID: 32773727 PMCID: PMC8342838 DOI: 10.4097/kja.20327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19)-associated coagulopathy is most often characterized by elevated D-dimer, interleukin-6, and plasma fibrinogen concentrations as well as hypercoagulability in thromboelastometry with increased clot firmness in the EXTEM, INTEM, and FIBTEM assays. Clinically, it manifests with a very high incidence of thrombosis, particularly in the pulmonary system, whereas bleeding complications are infrequent. CASE Here, we describe two critically ill patients with COVID-19 admitted to our intensive care unit demonstrating different thromboelastometry and biomarker patterns. One patient presented with hypercoagulability and the other patient with hypocoagulability and fibrinolysis shutdown in thromboelastometry. The pathophysiology and the potential impact on treatment options are discussed. CONCLUSIONS A combination of biomarkers and thromboelastometry results can be helpful in the future to decide which therapeutic strategy might be most appropriate for critically ill patients with COVID-19. This would be an important step to establish precision medicine in this high-risk patient population.
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Affiliation(s)
- Robert Kong
- Department of Anesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Nevil Hutchinson
- Department of Anesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, and Tem Innovations, Munich, Germany
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17
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Ichinomiya T, Murata H, Sekino M, Sato S, Higashijima U, Matsumoto S, Ishizaki H, Yoshitomi O, Maekawa T, Eguchi S, Hara T. Postoperative coagulation profiles of patients undergoing adult-to-adult living donor liver transplantation—A single-center experience. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2019.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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18
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Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72:297-322. [PMID: 31096732 PMCID: PMC6676023 DOI: 10.4097/kja.19169] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, San Sebastián de los Reyes, Madrid, Spain
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, CologneMerheim Medical Center (CMMC), Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany
| | - Ángel Augusto Pérez Calatayud
- Terapia Intensiva Adultos, Hospital de Especialidades del Niño y la Mujer, Coordinador Grupo Mexicano para el Estudio de la Medicina Intensiva, Colegio Mexicano de Especialistas en Obstetrica Critica (COMEOC), Queretarco, Mexico
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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19
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Yokoyama APH, Kutner JM, Sakashita AM, Nakazawa CY, de Paula TAO, Zamper RPC, Pedroso PT, de Almeida MD, Meira Filho SP, Orsi FA. Risk Factors for Transfusion after Orthotopic Liver Transplantation. Transfus Med Hemother 2019; 46:431-439. [PMID: 31933573 DOI: 10.1159/000499120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background Transfusion of blood products during orthotopic liver transplantation (OLT) is associated with increased morbidity and mortality. Although risk factors associated with intraoperative transfusion requirements have been widely assessed, published data on the prediction of postoperative transfusion requirements are sparse. Objectives The aim of this study was to evaluate risk factors for postoperative allogeneic transfusion requirements in OLT. Methods Clinical characteristics and intraoperative parameters of 645 consecutive adult patients undergoing OLT were retrospectively reviewed. Multivariate logistic regression was used to determine the main determinants for postoperative transfusion requirements. Results Determinants of postoperative transfusion requirements of any blood product in the postoperative period were the number of blood products transfused in the intraoperative period (OR 1.17, 95% CI 1.08-1.28), warm ischemia time (OR 1.05, 95% CI 1.02-1.08), MELD score (OR 1.05, 95% CI 1.01-1.08) and hepatocellular carcinoma (OR 0.45, 95% CI 0.28-0.72). A dose-dependent effect between the number of units transfused in the intraoperative period and transfusion requirements in the postoperative period was also observed. The relative risk of postoperative allogeneic transfusion of any blood component was 5.9 (95% CI 3.4-10.4) for patients who received 1-2 units in the intraoperative period, 7.3 (95% CI 3.6-14.7) for those who received 3-5 units in the intraoperative period, and 11.1 (95% CI 4.7-26.4) for those who received 6 or more units, when compared to no intraoperative blood transfusion. Conclusion Our study demonstrated an association between intraoperative transfusion and warm ischemia time with postoperative transfusion requirements. The identification of risk factors for transfusion in the postoperative period may improve management of these patients by increasing awareness to bleeding complications in this high-risk population and by expanding hemostasis monitoring to the postoperative period.
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Affiliation(s)
| | - José Mauro Kutner
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Araci Massami Sakashita
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Pamella Tung Pedroso
- Liver Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
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