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The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management

Forkin, Katherine, T., MD*; Colquhoun, Douglas, A., MBChB, MSc, MPH; Nemergut, Edward, C., MD*,‡; Huffmyer, Julie, L., MD*

doi: 10.1213/ANE.0000000000002394
Hemostasis: Narrative Review Article

The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease.

Published ahead of print August 8, 2017.

From the *Department of Anesthesiology, University of Virginia, Charlottesville, Virginia

Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan

Department of Neurosurgery, University of Virginia, Charlottesville, Virginia.

Published ahead of print August 8, 2017.

Accepted for publication July 11, 2017.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Julie L. Huffmyer, MD, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908. Address e-mail to

© 2018 International Anesthesia Research Society
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