Abstract

Case Presentation

Pitfalls in the hemostatic management of a liver transplantation

Raveh Yehuda* and Nicolau-Raducu Ramona

Published: 13 April, 2022 | Volume 6 - Issue 1 | Pages: 001-005

Liver Transplantation is fraught with thrombo-hemorrhagic complications, due to the precarious hemostasis of the recipient, anhepatic conditions, and the release of hemostatic factors from the allograft. Disseminated intravascular coagulation and its “flat-line” variant are common causes of hemorrhage and thrombosis, and frequently force the clinician along with a delicate balance between hemorrhage and thrombosis. We present a case that highlights some of the more challenging diagnostic and management decisions in liver transplantation and presents a safe and carefully structured approach to hyperfibrinolysis in liver transplantation.

Read Full Article HTML DOI: 10.29328/journal.acgh.1001032 Cite this Article Read Full Article PDF

References

  1. Gologorsky E, De Wolf AM, Scott V, Aggarwal S, Dishart M, et al. Intracardiac thrombus formation and pulmonary thromboembolism immediately after graft reperfusion in 7 patients undergoing liver transplantation. Liver Transpl. 2001; 7: 783-789. PubMed: https://pubmed.ncbi.nlm.nih.gov/11552212/
  2. Lerner AB, Sundar E, Mahmood F, Sarge T, Hanto DW, et al. Four cases of cardiopulmonary thromboembolism during liver transplantation without the use of antifibrinolytic drugs. Anesth Analg. 2005; 101: 1608-1612. PubMed: https://pubmed.ncbi.nlm.nih.gov/16301227/
  3. Sakai T, Matsusaki T, Dai F, Tanaka KA, Donaldson JB, et al. Pulmonary thromboembolism during adult liver transplantation: incidence, clinical presentation, outcome, risk factors, and diagnostic predictors. British J Anaesth. 2012; 108: 469-477. PubMed: https://pubmed.ncbi.nlm.nih.gov/22174347/
  4. Warnaar N, Molenaar IQ, Colquhoun SD, Slooff MJH, Sherwani S, et al. Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review. J Thromb Haemost. 2008; 6: 297-302. PubMed: https://pubmed.ncbi.nlm.nih.gov/18005235/
  5. Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth. 2018; 22: 150-163. PubMed: https://pubmed.ncbi.nlm.nih.gov/29099334/
  6. Bezinover D, Dirkmann D, Findlay J, Guta C, Hartmann M, et al. Perioperative Coagulation Management in Liver Transplant Recipients. Transplantation. 2018; 102: 578-592. PubMed: https://pubmed.ncbi.nlm.nih.gov/29337842/
  7. Raveh Y, Shatz V, Lindsay M, Nicolau-Raducu R. Disseminated intravascular coagulation during liver transplantation unleashed by protamine. J Clin Anesth. 2019; 57: 117-118. PubMed: https://pubmed.ncbi.nlm.nih.gov/30991212/
  8. Patrassi GM, Sartori MT, Sgarabotto D, Sturniolo G, Boeri G, et al. A DIC-like picture on plasma and ascitic fluid of cirrhotic patients. Res Exp Med. 1988; 188: 351-356. PubMed: https://pubmed.ncbi.nlm.nih.gov/3147501/
  9. Tang HH, Salem HH, Wood LJ, Dudley FJ. Coagulopathy during ascites reinfusion: prevention by antiplatelet therapy. Gastroenterology. 1992; 102: 1334-1339. PubMed: https://pubmed.ncbi.nlm.nih.gov/1551539/
  10. Nicolau-Raducu R, Beduschi T, Vianna R, Diez C, Sleem M, et al. Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation. Liver Transplantatio. 2019; 25: 380-387. PubMed: https://pubmed.ncbi.nlm.nih.gov/30548128/
  11. Tripodi A, Primignani M, Chantarangkul V, Dell'Era A, Clerici M, et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology. 2009; 137: 2105-2111. PubMed: https://pubmed.ncbi.nlm.nih.gov/19706293/
  12. Tripodi A, Mannucci PM. The Coagulopathy of Chronic Liver Disease. New Engl J Med. 2011; 365: 147-156. PubMed: https://pubmed.ncbi.nlm.nih.gov/21751907/
  13. Drebes A, de Vos M, Gill S, Fosbury E, Mallett S, et al. Prothrombin Complex Concentrates for Coagulopathy in Liver Disease: Single-Center, Clinical Experience in 105 Patients. Hepatol Commun. 2019; 3: 513-524. PubMed: https://pubmed.ncbi.nlm.nih.gov/30976742/
  14. Lip GY, Gibbs CR. Does heart failure confer a hypercoagulable state? Virchow's triad revisited. J Am Coll Cardiol. 1999; 33: 1424-1426. PubMed: https://pubmed.ncbi.nlm.nih.gov/10193748/
  15. Rasche H. Haemostasis and thrombosis: an overview. Eur Heart J Suppl. 2001; 3: Q3-Q7.
  16. Nielsen VG. Nitric oxide decreases coagulation protein function in rabbits as assessed by thromboelastography. Anesth Analg. 2001; 92: 320-323. PubMed: https://pubmed.ncbi.nlm.nih.gov/11159223/
  17. Hunt BJ, Segal H. Hyperfibrinolysis. J Clini Pathol. 1996; 49: 958. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC499639/
  18. Nicolau-Raducu R, Occhipinti E, Marshall T, et al. Thromboprophylaxis With Heparin During Orthotopic Liver Transplantation: Comparison of Hepcon HMS Plus and Anti-Xa Assays for Low-Range Heparin. J Cardiothorac Vasc Anesth. 2017; 31: 575-581. PubMed: https://pubmed.ncbi.nlm.nih.gov/27745797/
  19. Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizing transfusion strategies in damage control resuscitation: current insights. J Blood Med. 2018; 9: 117-133. PubMed: https://pubmed.ncbi.nlm.nih.gov/30154676/
  20. Raveh Y, Rodriguez Y, Pretto E, Souki F, Shatz V, et al. Thrombotic and hemorrhagic complications during visceral transplantation: risk factors, and association with intraoperative disseminated intravascular coagulation-like thromboelastographic qualities: a single-center retrospective study. Transpl Int. 2018; 31: 1125-1134. PubMed: https://pubmed.ncbi.nlm.nih.gov/29786890/
  21. Nickson C. Thromboelastogram (TEG). 2019. PubMed: https://litfl.com/thromboelastogram-teg/
  22. Farkas J. PulmCrit- Coagulation balance in sepsis-associated DIC. 2016. PubMed: https://emcrit.org/pulmcrit/sepsis-dic/
  23. Müller MCA, Meijers JC, van Meenen DM, Thachil J, Juffermans NP. Thromboelastometry in critically ill patients with disseminated intravascular coagulation. Blood Coagul Fibrinolysis. 2019; 30: 181-187. PubMed: https://pubmed.ncbi.nlm.nih.gov/31157682/
  24. Sivula M, Pettilä V, Niemi TT, Varpula M, Kuitunen AH. Thromboelastometry in patients with severe sepsis and disseminated intravascular coagulation. Blood Coagulation & Fibrinolysis. 2009; 20: 419-426. PubMed: https://pubmed.ncbi.nlm.nih.gov/19581801/
  25. Hendriks HGD, Meijer K, de Wolf JTM, Porte RJ, Klompmaker IJ, et al. Effects of recombinant activated factor VII on coagulation measured by thromboelastography in liver transplantation. Blood Coagul Fibrinolysis. 2002; 13: 309-313. PubMed: https://pubmed.ncbi.nlm.nih.gov/12032396/
  26. Verbeek TA, Stine JG, Saner FH, Bezinover D. Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplant Direct. 2018; 4: e403. PubMed: https://pubmed.ncbi.nlm.nih.gov/30534594/
  27. Harding SA, Mallett SV, Peachey TD, Cox DJ. Use of heparinase modified thrombelastography in liver transplantation. Br J Anaesth. 1997; 78: 175-179. PubMed: https://pubmed.ncbi.nlm.nih.gov/9068337/
  28. Kim EH, Song SH, Kim GS, Ko JS, Gwak MS, et al. Evaluation of "flat-line" thromboelastography after reperfusion during liver transplantation. Transpl Proc. 2015; 47: 457-459. PubMed: https://pubmed.ncbi.nlm.nih.gov/25769590/
  29. Asakura H. Classifying types of disseminated intravascular coagulation: clinical and animal models. J Intensive Care. 2014; 2: 20. PubMed: https://pubmed.ncbi.nlm.nih.gov/25520834/
  30. Hayakawa M. Pathophysiology of trauma-induced coagulopathy: disseminated intravascular coagulation with the fibrinolytic phenotype. J Intensive Care. 2017; 5: 14. PubMed: https://pubmed.ncbi.nlm.nih.gov/28289544/
  31. El-Baghdadi MM, Sakai T. Fatal Pulmonary Embolism During Liver Transplantation in a Patient With Fulminant Hepatic Failure: A Diagnostic Challenge of the “Flat-Line” Thromboelastogram. J Cardiothorac Vasc Anesth. 2010; 24: 641-643. PubMed: https://pubmed.ncbi.nlm.nih.gov/19819727/

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