Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short-term outcomes after liver transplantation - A systematic review of the literature and expert panel recommendations

Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA. Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, Toronto, Ontario, Canada. Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania, USA. Transplant Anesthesia & Critical Care, University of Pisa, Pisa, Italy. Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA. Department of Anaesthesiology, Royal Free London NHS Foundation Trust, London, UK. Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK. Division of Surgery & Interventional Science, University College London, UK. Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.

Clinical transplantation. 2022;:e14637
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Abstract
BACKGROUND Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease which is often multifactorial. OBJECTIVES The objective of this systematic review was to identify evidence-based intraoperative transfusion and coagulation management strategies that improve immediate and short-term outcomes after LT. METHODS PRISMA-guidelines and GRADE-approach were followed. Three sub-questions were formulated. (Q); Q1: transfusion management; Q2: antifibrinolytic therapy; and Q3: coagulation monitoring. RESULTS 16 studies were included for Q1, 6 for Q2, and 10 for Q3. Q1: PRBC and platelet transfusions were associated with higher mortality. The use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) were not associated with reductions in intraoperative transfusion or increased thrombotic events. The use of cell salvage was not associated with HCC recurrence or mortality. Cell salvage and transfusion education significantly decreased blood product transfusions. Q2: Epsilon-aminocaproic acid and Tranexamic acid were not associated with decreased blood product transfusion, improvements in patient or graft survival, or increases in thrombotic events. Q3: Viscoelastic testing was associated with decreased allogeneic blood product transfusion compared to conventional coagulation tests and are likely to be cost-effective. Coagulation management guided by VET may be associated with increases in fibrinogen concentrate and PCC use. CONCLUSION Q1: A specific blood product transfusion practice is not recommended. (QOE; low Recommendation; weak). Cell salvage and educational interventions are recommended. (QOE: low | Grade of Recommendation: moderate). Q2: The routine use of antifibrinolytics is not recommended. (QOE; low | Recommendation; weak). Q3: The use of VET is recommended. (QOE; low-moderate | Recommendation; strong). This article is protected by copyright. All rights reserved.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine