How Much Is the Inevitable Loss of Different Coagulation Factors During Blood Product-Free Liver Transplantations?

BACKGROUND: Bloodless liver transplantations (LT) have already been reported, but special characteristics of hemostatic changes remain less defined. The aim of this study was to evaluate the "inevitable" loss of coagulation factors (CF) in blood product-free LT. METHODS: Blood product and CF concentrate-free LT patient data were analyzed in terms of the first 2 days of perioperative hemostasis kinetics (N = 59). CF levels (FI, II, V, VII, X, and XIII), platelet (PLT) levels, and hemoglobin levels were measured before LT (T1), on arrival at the intensive care unit (T2), and 12, 24, and 48 hours after LT (T3, T4, and T5, respectively). Thromboelastographic (TEG) parameters were determined before and at the end of LT (T1-T2). RESULTS: Fibrinogen levels decreased by 1.2 ± 0.6 g/L, prothrombin levels by 26% ± 14%, factor V levels by 40% ± 23%, VII levels by 29% ± 19%, and X levels by 39% ± 22% (P < .001). From T2 to T4 fibrinogen increased by 0.9 ± 0.6g/L for 24 hours (P < .001). Factor II, V, and VII levels increased by 20% ± 16%, 31% ± 32%, and 12% ± 27%, respectively, between T3 and T5 (P < .001). However, factor X reached only half of the T1 level (T3-T5, P < .001). Platelet count increased in 34 (58%) patients at T2 (P < .001). The TEG parameters remained in the normal range during LT (T1-T2). CONCLUSION: The major findings of this study advocate that "inevitable" levels of CF decrease during LT by an average of 1.2 g/L in terms of fibrinogen and 23% to 40% regarding factors II, V, VII, and X. The authors suggest that knowing the "magic numbers" and comparing them against baseline laboratory results might predict the possibility of blood product-free transplant, providing confidence and safety to the surgeon and the anesthetist.

Epidural anesthesia? No of course.

Although the contraindications for thoracic epidural anesthesia (TEA) are well defined, the debate continues about whether TEA improves outcomes. Pro and con trials and a metaanalysis in the past have yielded equivocal results; they did not deal with new vascular intervention or drugs. The benefit of TEA in surgery is to provide analgesia. In subgroups, TEA can decrease the mortality and morbidity. In contrast, the cost can increase in the situation of a complication that is opposite to the side effects is rare, but the impairment caused by them is out of proportion to the benefits. Primary or secondary prophylaxis with antithrombotic drugs is increasing in developed countries because of the increasing cardiovascular interventions and aging of the population. The neuroaxial guidelines are useful, but the changing of the coagulation profile after hepatectomy is not included in them. The decision to use TEA in liver surgery must be individualized with steps planned from the beginning. TEA suitability is based on an evaluation of the contraindications, comorbidities, coagulation profiles, hepatic reserve, and balance of benefits and risks. The insertion or withdrawal of the epidural catheter should be made with care according to the neuroaxial guidelines and in the presence of a normal TEG. The decreasing level of prothrombin content and platelet counts after hepatectomy should be closely monitored every 2 to 5 days.

Evaluation of liver function for hepatic resection.

New limits have been established to decrease mortality and morbidity rates after liver resection in cirrhotic and non-cirrhotic patients. Various laboratory data and imaging techniques have been used to complement the Child-Pugh score to predict liver failure after hepatectomy and to assess functional hepatic reserve. The greatest experiences are with the aminopyrine breath test and the galactosyl elimination capacity, which are decreased among hepatic failure patients after liver resection. However, absence of these changes do not totally exclude it. The indocyanine green retention test is the most widely used clearance test. Nevertheless, it remains imperfect because it depends both on hepatic blood flow and on the functional capacity of the liver. Nuclear imaging of the asialoglicoprotein receptors with radiolabelled synthetic asialoglicoproteins provides volumetric information as well a functional assessment of the liver. In summary, while liver function is complex, a successful liver test to assess quantitative functional hepatic reserve still needs to be established. The combination of the Child-Pugh score, the presence of ascites, the serum bilirubin levels, the indocyanine green retention (ICG R15) value, and the remnant liver CT volumetry seems to avoid an index of liver failure after hepatic resection. Cases when ICG R15 is above 15% should be combined with portal vein embolization. If there is no possibility to perform an ICG clearance test, it may be replaced with other available, well known dynamic liver function tests.