Intraoperative coagulation monitoring and small bowel transplantation: a way to explore.

BACKGROUND: The existence of coagulation disorders during intestinal transplantation is getting more important for a correct anesthetic management. Both a condition of hypocoagulation and hypercoagulation can happen during the intraoperative course. Thromboelastography (TEG), a test on whole blood coagulation, allows measurement of different phases of coagulation function. The aims of our study were to evaluate coagulation derangements during bowel transplantation using TEG. MATERIALS AND METHODS: We measured cold ischemia time in 19 patients who underwent general anesthesia for intestinal transplantation. We measured five TEG indicators (R, K, angle, MA, CL50) at defined intervals: dissection phase (T1), vascular anastomosis phase (T2), 30' (T3) and 120' (T4) after reperfusion during the intestinal reconstruction. RESULTS: We found a statistically significant difference between MA measured at T1 versus T3 and T4. There was no significant relation between MA derangements and ischemia time. CONCLUSIONS: Patients showed hypocoagulation pattern during all periods. MA indicator variation between the initial value and the value after reperfusion may relate to release of hypocoagulation factors. We observed important coagulation derangements during small bowel transplantation, particularly on platelet function after graft reperfusion. The derangements did not depend on ischemia time.

Intraoperative coagulation evaluation of ischemia-reperfusion injury in small bowel transplantation: a way to explore.

BACKGROUND AND AIM OF STUDY: The success of intestinal transplantation is affected by the extreme susceptibility of the small bowel to ischemia-reperfusion (I/R) injury. Platelet aggregation decreases after reperfusion in small intestinal ischemia and liver transplantation. Thromboelastography (TEG) is a coagulation test performed whole on blood. The aims of this study were to assess coagulation derangements during bowel transplantation to define appropriate modalities of intraoperative coagulation monitoring. A secondary endpoint was to determine whether measurements of coagulation derangements were useful to estimate small intestinal I/R injury. MATERIALS AND METHODS: We recruited 19 patients who had undergone elective small bowel transplantation for primary short-gut syndrome. We divided our patients into two groups depending on their reperfusion injury as evaluated with a biopsy after reperfusion: group A composed of eight patients who had a reperfusion injury: group B composed of 11 patients who did not experience this problem. We measured five thromboelastogram indicators (r, k, angle, MA, CL30) at defined intervals: dissection phase (T1), vascular anastomoses phase (T2) as well as 30 minutes (T3) and 120 minutes (T4) after reperfusion during the intestinal reconstruction phase. RESULTS: We did not observe any significant difference between intraoperative blood loss, core temperature, or volume of fluid fresh frozen plasma, or platelet administration. Angle and MA were decreased significantly among patients with reperfusion injury. DISCUSSION: Patients showed a hypocoagulation pattern during all the manipulations. This derangement did not depend on the ischemia time. In patients with I/R injury the angle and MA did not change during ischemia, but did change significantly upon reperfusion. Several mechanisms may cause coagulation derangements. During the ischemic period, there may be damage to the vascular bed of the ischemic organ. When arterial blood passes through the damaged vascular bed after reperfusion, platelet activation occurs to varying degrees, resulting in reduced platelet function. CONCLUSION: Further studies are needed to confirm this preliminary work, which was limited by the low number of patients, in order to elucidate relevant mechanisms and develop predictive algorithms.