Point-of-care haemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome
Introduction
Orthotopic-liver-transplantation (OLT) has become the first-line approach for the treatment of patients with end-stage liver disease [1], [2]. As a result of improvement in anesthesiological and surgical skill, organ support device adoption, advanced understanding of transplant immunology, and better critical care management of complications, liver transplanted patients survive longer. However, OLT has been associated with severe bleeding and subsequent massive transfusion of allogeneic blood products, such as plasma, platelets and red blood cells (RBC) [3]. Substantial evidence suggests that the use of blood products during OLT is associated with a number of post-operative adverse events and may negatively affect the evolution of the procedure, resulting in a limited success on an individual basis [4], [5]. High volume of fresh frozen plasma (FFP) transfusion is considered as a predictor of postoperative bleeding risk [6] and platelet transfusion has also been identified as an independent risk factor for adverse postoperative outcomes [7].
Severe bleeding in OLT is related to both existing co-morbidities and the procedure itself [8]. Due to the complex nature of the haemostatic response to surgery, an interaction of plasma proteins, platelets, and the vessel wall [9], routine laboratory plasma coagulation tests running in the main laboratory, such as international normalised ratio (INR) and activated partial thromboplastin time (aPTT), are not sufficient to diagnose specific coagulation defects and to guide haemostatic therapy. Instead, whole blood monitoring strategies sensitive to all major pathomechanisms are more informative. In OLT surgery, where events often progress at a fast and dramatic pace, minimising the delay in collecting test results from a central laboratory is critical to efficient haemostasis management. However, determining the optimal approach to diagnosis and treatment of defective haemostasis remains one of the greatest challenges in OLT [10], [11].
Point-of-care (POC) testing may overcome some of the limitations of traditional approaches to haemostasis management [12], [13]. In contrast to routine coagulation tests, results from POC devices can be obtained within a few minutes, allowing goal-directed therapy to be rapidly initiated. In addition, POC testing allows the differential diagnosis of specific coagulopathies. The use of POC-guided haemostatic therapy is critical in optimising massive transfusion management and reducing overall blood loss [14], [15], and recent guidelines recommend the inclusion of POC coagulation monitoring in the perioperative management of bleeding patients [16], [17]]. Despite the large number of published studies in this area, precisely how haemostatic assessment should be carried out in the setting of OLT is not clearly defined in the literature. Although multiple trials have evaluated different approaches to haemostatic management in other settings [18], [19], [20], the evidence in other surgical settings with substantial blood loss, such as OLT, is lacking.
In this study, we evaluated the impact of a new approach for haemostatic and transfusion management based in POC monitoring in OLT. Our first aim was to evaluate the impact on transfusion requirements; numbers of units of blood product given per patient intraoperatively, the proportion of patients who completely avoided blood product transfusion (total avoidance), and the proportion of patients who received massive transfusion (defined as the transfusion of more than 10 RBC units). The second aim was to evaluate the impact in adverse patient outcomes, defined as the rate of occurrence of immediate postoperative complications.
Section snippets
Study population
We evaluated 200 consecutive OLTs performed at the Virgen del Rocio University Hospital in Seville, Spain, between October 2009 and July 2012. This study was performed following approval of the VRUH ethics committee (PI/132) and in accordance with the Declaration of Helsinki and Good Clinical Practice. Informed consent was obtained for all patients. Patient characteristic, details of the surgery, transfusion requirements, laboratory test results and immediate postoperative complications were
Patient characteristics and transfusion requirements
200 consecutive OLTs were performed, the summary of patients' characteristics, pathologies and preoperative variables is presented in Table 1. The median MELD score was 18 and the most frequent pathology prior to OLT was alcoholic liver disease. Age and diagnosis of combined alcoholic liver disease and hepatitis B or hepatitis C, were higher in the POC group. For other patient characteristics, there was no significant difference. Preoperative variables were similar, the median of starting Hb
Discussion
In this study, we evaluated the impact in transfusion requirement and patient outcomes of a new approach for haemostasis and transfusion management based in POC monitoring in OLT. We found that patients under POC monitoring received fewer allogeneic blood product transfusions than those monitored using the current standard procedure based in routine testing performed in the main laboratory. In addition, we found that more patients avoided blood product transfusion and massive transfusion and
Funding and resources
The authors have no grant support or industry funding.
Declaration of author's contributions
All authors contributed equally to the design, data collection, biochemical analyses, data analysis, drafting and its approving final version of manuscript.
Conflict of interest
The authors have no conflicts to declare.
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