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Current Transplantation Reports

, Volume 5, Issue 3, pp 251–263 | Cite as

Current Hematological Concepts and Viscoelastic-Based Transfusion Practices During Liver Transplantation

  • Arun UthayashankarEmail author
  • Michael Kaufman
Anesthesia and Critical Care in Transplantation (D Axelrod and M Kaufman, Section Editors)
  • 41 Downloads
Part of the following topical collections:
  1. Topical Collection on Anesthesia and Critical Care in Transplantation

Abstract

Purpose

When the cascade model of coagulation was postulated in 1964, it convincingly explained the conventional tests of coagulation and their therapeutic applications for existing anticoagulants. But the conventional tests only tend to measure the procoagulant factors and not the anticoagulant factors present in the blood, as a result, the coagulation concept was updated to cell-based model in 2001. Despite these facts, the conventional tests are still used perioperatively in liver transplantation for blood product management, at the risk of causing over-transfusion and deleterious prothrombotic effects. This article reviews the current understanding of coagulation and suggests an improved method to manage intraoperative blood product replacement.

Recent Findings

We set out to develop a diagnostic and dosing protocol based on viscoelastic tests, which more accurately reflect the dynamic interplay between pro and anticoagulants in the end-stage liver disease patient. This approach reduces the overtransfusion and resulting harm from excessive coagulation without increasing the risk of intraoperative bleeding.

Conclusion

While we were successful in formulating a dosing regimen based on available literature and our own institutional practices for treating deficiencies of clotting factors and fibrinogen, more research is needed to arrive at a dosing regimen for platelets based on functional deficiency.

Keywords

Liver transplant Current concepts Hematology Viscoelastic tests ROTEM-based protocol 

Abbreviations

ADAMTS

A Disintegrin And Metalloproteinase with a ThromboSpondin Type 1 motif

ADP

adenosine diphosphate

APTEM

aprotinin-added ROTEM

aPTT

activated partial thromboplastin time

AT

antithrombin

CFT

clot formation time

CT

clotting time

ESLD

end-stage liver disease

EXTEM

extrinsic pathway component of ROTEM

Gp

glycoprotein

HEPTEM

heparinase-added ROTEM

INTEM

intrinsic pathway component of ROTEM

Leu

leucine

LT

liver transplant

MCF

maximum clot formation

ML

maximum lysis

PAF

platelet-activating factor

PAI

plasminogen activator inhibitor

PAR

protease-activated receptors

PI

plasmin inhibitor

PT

prothrombin time

RGD

arginine-glycine-D aspartate

ROTEM

rotational thromboelastometry

TAFI

thrombin activatable fibrinolysis inhibitor

TEG

thromboelastogram

TF

tissue factor

TFPI

tissue factor pathway inhibitor

TM

thrombomodulin

tPa

tissue plasminogen activator

uPa

urine plasminogen activator

val

valine

vWF

von Willebrand factor

Notes

Compliance with Ethical Standards

Conflict of Interest

Arun Uthayashankar and Michael Kaufman declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Lahey Hospital and Medical CenterBurlingtonUSA
  2. 2.Tufts University School of MedicineBostonUSA
  3. 3.LongmeadowUSA

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