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BMC Anesthesiology
Published in: BMC Anesthesiology 1/2018

Open Access 01-12-2018 | Technical advance

Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study

Authors: Raffael P. C. Zamper, Thiago C. Amorim, Veronica N. F. Queiroz, Jordana D. O. Lira, Luiz Guilherme V. Costa, Flavio Takaoka, Nicole P. Juffermans, Ary S. Neto

Published in: BMC Anesthesiology | Issue 1/2018

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Abstract

Background

Perioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation.

Methods

This is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality.

Results

A total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20–0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08–0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03–0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality.

Conclusions

Use of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation.

Trial registration

This trial was registered retrospectively on November 15th, 2018 – clinicaltrials.​gov – Identifier: NCT03756948.
Appendix
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Literature
1.
Rana A, Petrowsky H, Hong JC, Agopian VG, Kaldas FM, Farmer D, Yersiz H, Hiatt JR, Busuttil RW. Blood transfusion requirement during liver transplantation is an important risk factor for mortality. J Am Coll Surg. 2013;216(5):902–7.PubMedCrossRef
2.
3.
4.
Maxwell MJ, Wilson MJA. Complications of blood transfusion. Contin Educ Anaesth Crit Care Pain. 2006;6:225–9.CrossRef
5.
6.
Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg. 2004;98(5):1245–51.PubMedCrossRef
7.
Yuasa T, Niwa N, Kimura S, Tsuji H, Yurugi K, Egawa H, Tanaka K, Asano H, Maekawa T. Intraoperative blood loss during liver transplantation: an analysis of 635 recipients at a single center. Transfusion. 2005;45(6):879–84.PubMedCrossRef
8.
Warner P, Fusai G, Glantzounis GK, Sabin CA, Rolando N, Patch D, Sharma D, Davidson BR, Rolles K, Burroughs AK. Risk factors associated with early hepatic artery thrombosis after orthotopic liver transplantation - univariable and multivariable analysis. Transpl Int. 2011;24(4):401–8.PubMedCrossRef
9.
de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, Slooff MJ, Porte RJ. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg. 2008;106(1):32–44.PubMedCrossRef
10.
Liu S, Fan J, Wang X, Gong Z, Wang S, Huang L, Xing T, Li T, Peng Z, Sun X. Intraoperative cryoprecipitate transfusion and its association with the incidence of biliary complications after liver transplantation--a retrospective cohort study. PLoS One. 2013;8(5):e60727.PubMedPubMedCentralCrossRef
11.
Ramos E, Dalmau A, Sabate A, Lama C, Llado L, Figueras J, Jaurrieta E. Intraoperative red blood cell transfusion in liver transplantation. Influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl. 2003;9(12):1320–7.PubMedCrossRef
12.
Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Busque S, Concepcion W, So SK, Esquivel CO. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg. 1999;134(1):25–9.PubMedCrossRef
13.
Goodnough LT, Brecher ME, Kanter H, AuBuchon JP. Transfusion medicine. First of two part - blood transfusion. N Engl J Med. 1999;340(6):438–47.PubMedCrossRef
14.
Goodnough LT, Brecher ME, Kanter H, AuBuchon JP. Transfusion medicine. Second of two parts - blood conservation. N Engl J Med. 1999;340(6):525–33.PubMedCrossRef
15.
Spahn DR, Casutt M. Eliminating blood transfusions. New aspects and perspectives. Anesthesiology. 2000;93(1):242–55.PubMedCrossRef
16.
Saner FH, Gieseler RK, Akız H, Canbay A, Gorlinger K. Delicate balance of bleeding and thrombosis in end-stage liver disease and liver transplantation. Digestion. 2013;88(3):135–44.PubMedCrossRef
17.
Tripodi A, Salerno F, Chantarangkul V, Clerice M, Cazzaniga M, Primignani M, Mannucci PM. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology. 2005;41(3):553–8.PubMedCrossRef
18.
Lisman T, Bakhtiari K, Pereboom IT, Hendriks HG, Meijers JC, Porte RJ. Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests. J Hepatol. 2010;52(3):355–61.PubMedCrossRef
19.
Tripodi A, Primignani M, Chantarangkul V, Clerici M, Dell’Era A, Fabirs F, Salerno F, Mannucci PM. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology. 2006;44(2):440–5.PubMedCrossRef
20.
Lisman T, Stravitz RT. Rebalanced hemostasis in patients with acute liver failure. Semin Thromb Hemost. 2015;41(5):468–73.PubMedCrossRef
21.
Tripodi A, Primignani M, Mannucci PM, Caldwell SH. Changing concepts of cirrhotic coagulopathy. Am J Gastroenterol. 2017;112(2):274–81.PubMedCrossRef
22.
Hartmann M, Szalai C, Saner FH. Hemostasis in liver transplantation: pathophysiology, monitoring, and treatment. World J Gastroenterol. 2016;22(4):1541–50.PubMedPubMedCentralCrossRef
23.
Kang YG, Martin DJ, Marquez J, Lewis JH, Bontempo FA, Shaw BW Jr, Starlz TE, Winter PM. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg. 1985;64(9):888–96.PubMedPubMedCentralCrossRef
24.
Hartert H. Blutgerinnungstudien mit der Thrombelastographie, einem neuen Untersuchungs verfahren. Klin Wochenschr. 1948;26(37–38):557–83.
25.
26.
27.
Weber CF, Görlinger K, Meininger D, Hermann E, Bingold T, Moritz A, Cohn LH, Zacharowski K. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology. 2012;117(3):531–47.PubMedCrossRef
28.
Davenport R, Khan S. Management of major trauma haemorrhage: treatment priorities and controversies. Br J Haematol. 2011;155(5):537–48.PubMedCrossRef
29.
Wang SC, Shieh JF, Chang KY, Chu YC, Liu CS, Loong CC, Chan KH, Mandell S, Tsou MY. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc. 2010;42(7):2590–3.PubMedCrossRef
30.
31.
Gurusamy KS, Pissanou T, Pikhart H, Vaughan J, Burroughs AK, Davidson BR. Methods to decrease blood loss and transfusion requirements for liver transplantation. Cochrane Database Syst Rev. 2011;12:CD009052.
32.
Freitas AC, Itikawa WM, Kurogi AS, Stadnik LG, Parolin MB, Coelho JC. The impact of the model for end-stage liver disease (MELD) on liver transplantation in one center in Brazil. Arq Gastroenterol. 2010;47(3):233–7.PubMedCrossRef
33.
Varotti G, Santori G, Andorno E, Morelli N, Ertreo M, Strada P, Porcile E, Casaccia M, Centanaro M, Valente U. Impact of model for end-stage liver disease score on transfusion rates in liver transplantation. Transplant Proc. 2013;45(7):2684–8.PubMedCrossRef
34.
Görlinger K, Dirkmann D, Hanke AA, Kamler M, Kottenberg E, Thielmann M, Jakob H, Peters J. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology. 2011;115(6):1179–91.PubMed
35.
Agarwal A, Sharma N, Vij V. Point-of-care coagulation monitoring during liver transplantation. Trends in Anaesthesia and Critical Care. 2013;3:42–8.CrossRef
36.
Blasi A, Beltran J, Pereira A, Martinez-Palli G, Torrents A, Balust J, Zavala E, Taura P, Garcia-Valdecasas JC. An assessment of thromboelastometry to monitor blood coagulation and guide transfusion support in liver transplantation. Transfusion. 2012;52(9):1989–98.PubMedCrossRef
37.
McCluskey SA, Karkouti K, Wijeysundera DN, Kakizawa K, Ghannam M, Hamdy A, Grant D, Levy G. Derivation of a risk index for the prediction of massive blood transfusion in liver transplantation. Liver Transpl. 2006;12(11):1584–93.PubMedCrossRef
38.
Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesth Analg. 2008;106(5):1366–75.PubMedCrossRef
39.
Hanke AA, Herold U, Dirkmann D, Tsagakis K, Jakob H, Görlinger K. Thromboelastometry based early goal-directed coagulation management reduces blood transfusion requirements, adverse events, and costs in acute type a aortic dissection: a pilot study. Transfus Med Hemother. 2012;39(2):121–8.PubMedPubMedCentralCrossRef
40.
Lier H, Bottiger BW, Hinkelbein J, Krep H, Bernhard M. Coagulation management in multiple trauma: a systematic review. Intensive Care Med. 2011;37(4):572–82.PubMedCrossRef
41.
Gorlinger K, Fries D, Dirkmann D, Weber C, Hanke A, Schochl H. Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal- directed therapy. Transfus Med Hemother. 2012;39(2):104–13.PubMedPubMedCentralCrossRef
42.
Gorlinger K. Coagulation management during liver transplantation. Hamostaseologie. 2006;26(3 suppl 1):S64–76.PubMed
43.
Kirchner C, Dirkmann D, Treckmann JW, Paul A, Hartmann M, Saner FH, Gorlinger K. Coagulation management with factor concentrates in liver transplantation: a single-center experience. Transfusion. 2014;54(10Pt2):2760–8.PubMedCrossRef
44.
Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth. 2010;19(2):218–23.PubMedCrossRef
45.
Karlsson M, Ternstrom L, Hyllner M, Baghaei F, Flinck A, Skrtic S, Jeppsson A. Prophylactic fibrinogen infusion reduces bleeding after coronary artery bypass surgery. A prospective randomised pilot study. Thromb Haemost. 2009;102(1):137–44.PubMed
46.
Schochl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, Kozek-Langenecker S, Solomon C. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care. 2010;14(2):R55.PubMedPubMedCentralCrossRef
47.
Sorensen B, Bevan D. A critical evaluation of cryoprecipitate for replacement of fibrinogen. Br J Haematol. 2010;149(6):834–43.PubMedCrossRef
48.
Chowdhury P, Saayman AG, Paulus U, Findlay GP, Collins PW. Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol. 2004;125(1):9–73.CrossRef
49.
Rahe-Meyer N, Sorensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.PubMedCrossRef
50.
Palomo Sanchez JC, Jiménez C, Moreno Gonzalez E, Garcia I, Palma F, Loinaz C, Gonzalez Ghamorro A. Effects of intraoperative blood transfusion on postoperative complications and survival after orthotopic liver transplantation. Hepatogastroenterology. 1998;45(22):1026–33.PubMed
51.
Janatpour K, Holland PV. Noninfectious serious hazards of transfusion. Curr Hematol Rep. 2002;1(2):149–55.PubMed
52.
53.
Novakovic Anucin S, Kosanovic D, Gnip S, Canak V, Cabarkapa V, Mitic G. Comparison of standard coagulation tests and rotational thromboelastometryfor hemostatic system monitoring during orthotopic liver transplantation – results from a pilot study. Med Pregl. 2015;68(9–10):301–7.PubMedCrossRef
54.
Sabate A, Dalmau A. Fibrinogen: a clinical update on liver transplantation. Transplant Proc. 2015;47(10):2925–8.PubMedCrossRef
55.
Coakley M, Reddy K, Mackie I, Mallett S. Transfusion triggers in orthotopic liver transplantation: a comparison of the thromboelastometry analyzer, the thromboelastogram, and conventional coagulation tests. J Cardiothorac Vasc Anesth. 2006;20(4):548–53.PubMedCrossRef
56.
Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg. 2009;108(4):1083–91.PubMedCrossRef
57.
Roullet S, Pillot J, Freyburger G, Biais M, Quinart A, Rault A, Revel P, Sztark F. Rotation thromboelastometry detects thrombocytopenia and hypofibrinogenaemia during orthotopic liver transplantation. Br J Anaesth. 2010;104(4):422–8.PubMedCrossRef
58.
Sarode R, Milling TJ Jr, Refaai MA, Mangione A, Scheneider A, Durn BL, Goldstein JN. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation. 2013;128(11):1234–43.PubMedPubMedCentralCrossRef
59.
60.
Hanke AA, Joch C, Gorlinger K. Long-term safety and efficacy of a pasteurized nanofiltrated prothrombin complex concentrate (Beriplex P/N): a pharmacovigilance study. Br J Anaesth. 2013;110(5):764–72.PubMedCrossRef
61.
Abuelkasem E, Hasan S, Mazzeffi MA, Planinsic RM, Sakai T, Tanaka KA. Reduced requirement for prothrombin complex concentrate for the restoration of thrombin generation in plasma from liver transplant recipients. Anesth Analg. 2017;125(2):609–15.PubMedCrossRef
62.
Roullet S, Freyburguer G, Cruc M, Quinart A, Stecken L, Audy M, Chiche L, Sztark F. Management of bleeding and transfusion during liver transplantation before and after the introduction of a rotational thromboelastometry-based algorithm. Liver Transpl. 2015;21(2):169–79.PubMedCrossRef
63.
Song JG, Jeong SM, Jun IG, Lee HM, Hwang GS. Five-minute parameter of thromboelastometry is sufficient to detect thrombocytopenia and hypofibrinogenaemia in patients undergoing liver transplantation. Br J Anaesth. 2014;112(2):290–7.PubMedCrossRef
64.
Roullet S, Freyburger G, Labrouche S, Morisse E, Stecken L, Quinart A, Laurent C, Sztark F. Hyperfibrinolysis during liver transplantation is associated with bleeding. Thromb Haemost. 2015;113(5):1145–8.PubMedCrossRef
65.
Xia VW, Steadman RH. Antifibrinolytics in orthotopic liver transplantation: current status and controversies. Liver Transpl. 2005;11(1):10–8.PubMedCrossRef
66.
67.
Poon KS, Chen CC, Thorat A, Chiang YY, Jeng LB, Yang HR, Chen TH, Yeh CC, Chen KB. Fibrinolysis after reperfusion of liver graft. Acta Anaesthesiol Taiwanica. 2015;53(1):41–3.CrossRef
68.
Bolliger D, Seeberger MD, Tanaka KA. Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfus Med Rev. 2012;26(1):1–13.PubMedCrossRef
69.
70.
Metadata
Title
Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study
Authors
Raffael P. C. Zamper
Thiago C. Amorim
Veronica N. F. Queiroz
Jordana D. O. Lira
Luiz Guilherme V. Costa
Flavio Takaoka
Nicole P. Juffermans
Ary S. Neto
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2018
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-018-0664-8

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