2017, Number 6
The Optimal Transfusion Strategy in Liver Transplantation: The Quest Continues
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Smart, et al. Rotational Thromboelastometry or Conventional Coagulation Tests in Liver Transplantation: Comparing Blood Loss, Transfusions, and Cost. Annals of Hepatology.
The physiology of hemostasis in decompensated cirrhosis
is profoundly distinct from any other disease state
encountered during surgery. Our current understanding of
the coagulation system in cirrhosis has expanded significantly
over the last 15 years. This new paradigm relies
entirely on the concept of a rebalanced coagulation state,
where all of the components of the system are significantly
altered (both pro and anticoagulant portions), but maintained
in a precarious equilibrium. External disruption of
this balance, whether a consequence of disease progression
or from human intervention, can thrust the balance
into bleeding or thrombosis, often in dramatic fashion.
Liver transplantation represents one of the greatest physiological
insults to this balance. In the perioperative
period, both bleeding or thrombosis can be catastrophic,
which imbues a strong impulse to aim all measures at prevention.
However, without an adequate measure to
provide guidance, current efforts at prophylactic therapy
are often misguided and potentially counter-productive.
Particularly transfusion of large volumes of blood product
(excessive use of fresh frozen plasma (FFP)) can only
serve to potentiate portal hypertension and beget a vicious
cycle of bleeding.
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