Current Hematological Concepts and Viscoelastic-Based Transfusion Practices During Liver Transplantation
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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.
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.
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.
KeywordsLiver transplant Current concepts Hematology Viscoelastic tests ROTEM-based protocol
A Disintegrin And Metalloproteinase with a ThromboSpondin Type 1 motif
activated partial thromboplastin time
clot formation time
end-stage liver disease
extrinsic pathway component of ROTEM
intrinsic pathway component of ROTEM
maximum clot formation
plasminogen activator inhibitor
thrombin activatable fibrinolysis inhibitor
tissue factor pathway inhibitor
tissue plasminogen activator
urine plasminogen activator
von Willebrand factor
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.
Papers of particular interest, published recently, have been highlighted as: • Of importance
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