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The use of a thromboelastometry-based algorithm reduces the need for blood product transfusion during orthotopic liver transplantation

A randomised controlled study

Bonnet, Aurélie; Gilquin, Nathalie; Steer, Nadia; Gazon, Mathieu; Quattrone, Diego; Pradat, Pierre; Maynard, Marianne; Mabrut, Jean-Yves; Aubrun, Frederic

European Journal of Anaesthesiology (EJA): November 2019 - Volume 36 - Issue 11 - p 825–833
doi: 10.1097/EJA.0000000000001084
Coagulation
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BACKGROUND Orthotopic liver transplantation is associated with a risk of bleeding. Coagulation in cirrhotic patients is difficult to assess with standard coagulation tests because of rebalanced coagulation. This can be better assessed by thromboelastometry which can detect coagulation impairments more specifically in such patients.

OBJECTIVES Our first objective was to compare the number of units of blood products transfused during liver transplantation when using an algorithm based on standard coagulation tests or a thromboelastometry-guided transfusion algorithm.

DESIGN Randomised controlled trial.

SETTING Single-centre tertiary care hospital in France, from December 2014 to August 2016.

PARTICIPANTS A total of 81 adult patients undergoing orthotopic liver transplantation were studied. Patients were excluded if they had congenital coagulopathies.

INTERVENTION Transfusion management during liver transplantation was guided either by a standard coagulation test algorithm or by a thromboelastometry-guided algorithm. Transfusion, treatments and postoperative outcomes were compared between groups.

MAIN OUTCOME MEASURES Total number of transfused blood product units during the operative period (1 U is one pack of red blood cells (RBCs), fresh frozen plasma (FFP) or platelets).

RESULTS Median [interquartile range] intra-operative transfusion requirement was reduced in the thromboelastometry group (3 [2 to 4] vs. 7 [4 to 10] U, P = 0.005). FFP and tranexamic acid were administered less frequently in the thromboelastometry group (respectively 15 vs. 46.3%, P = 0.002 and 27.5 vs. 58.5%, P = 0.005), whereas fibrinogen was more often infused in the thromboelastometry group (72.5 vs. 29.3%, P < 0.001). Median transfusions of FFP (3 [2 to 6] vs. 4 [2 to 7] U, P = 0.448), RBCs (3 [2 to 5] vs. 4 [2 to 6] U, P = 0.330) and platelets (1 [1 to 2] vs. 1 [1 to 2] U, P = 0.910) were not different between groups. In the postoperative period, RBC or platelet transfusion, the need for revision surgery or occurrence of haemorrhage were not different between groups.

CONCLUSION A transfusion algorithm based on thromboelastometry assessment of coagulation reduced the total number of blood product units transfused during liver transplantation, particularly FFP administration.

TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02352181.

From the Département d’Anesthésie et Réanimation (AB, NG, NS, MG, DQ, FA), Département de Chirurgie Hépatobiliaire et de Transplantation hépatique (J-YM) and Centre de Recherche Clinique, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France (PP, MM)

Correspondence to Dr Aurélie Bonnet, Département d’Anesthésie et Réanimation, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France Tel: +33 4 26 10 93 35; e-mail: aurelie.bonnet@chu-lyon.fr

Published online 16 September 2019

© 2019 European Society of Anaesthesiology