Bleeding during transplant? Time for a change

Organ transplantation represents one of the major accomplishments of modern medicine over the last 50 years with liver transplantation progressing during that time from experimental therapy to standard of care with excellent outcomes. Advances in anesthesia and critical care during the operative and early postoperative period have played a major role in this success, along with the more obvious improvements in patient selection and immunosuppression. Management of even heavy intraoperative bleeding is now routine for most anesthesia teams and is perhaps only limited by early recognition.
Source: American Journal of Surgery - Category: Surgery Authors: Tags: Invited Commentary Source Type: research

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Publication date: Available online 1 October 2020Source: Anaesthesia Critical Care &Pain MedicineAuthor(s): François M. Carrier, André Y. Denault, Anna Nozza, Benjamin Rioux-Massé, André Roy, Luc Massicotte
Source: Anaesthesia, Critical Care and Pain Medicine - Category: Anesthesiology Source Type: research
Abstract OBJECTIVES: Orthotopic liver transplant can be accompanied by an obscure bleeding pattern in patients with severe hepatic malfunction. In the present study, coagulation conditions of patients with cirrhosis of the liver due to primary sclerosing cholangitis and nonbiliary causes of cirrhosis were compared using rotational thromboelastometry assays obtained before orthotopic liver transplant. MATERIALS AND METHODS: This case control study analyzed patients who were candidates for orthotopic liver transplant from 2010 to 2016. Eighty patients with cirrhosis of the liver (40 patients with primary sclero...
Source: Experimental and Clinical Transplantation : official journal of the Middle East Society for Organ Transplantation - Category: Transplant Surgery Authors: Tags: Exp Clin Transplant Source Type: research
INTRAOPERATIVE transesophageal echocardiography (TEE) is a valuable diagnostic and monitoring tool during liver transplantation (LT).1 Despite concerns about bleeding risk in patients with end-stage liver disease, multiple studies have established the safety and utility of TEE in this patient population.2,3 Although a majority of practicing LT anesthesiologists find intraoperative TEE to be clinically valuable, only a small percentage use it routinely or have obtained certification through the National Board of Echocardiography.
Source: Journal of Cardiothoracic and Vascular Anesthesia - Category: Anesthesiology Authors: Tags: Editorial Source Type: research
Publication date: Available online 29 January 2020Source: Best Practice &Research Clinical AnaesthesiologyAuthor(s): Alberto Zanetto, Marco Senzolo, Annabel BlasiAbstractEnd stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of anti-thrombotic treatment during and after transplant surgery is particularly difficult. Bleeding was traditionally considered the major concern during an...
Source: Best Practice and Research Clinical Anaesthesiology - Category: Anesthesiology Source Type: research
Publication date: Available online 17 December 2019Source: Best Practice &Research Clinical AnaesthesiologyAuthor(s): Ahmed Mukhtar, Ahmed Lotfy, Amr Hussein, Eman FouadThe interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In a patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from the systemic circulation into the splanchnic bed, which decreases the effective blood volume. Moreover, rapid volume loading in these patients has less impact on the cardiac output because a higher proportion of infused fluid is shifted to ...
Source: Best Practice and Research Clinical Anaesthesiology - Category: Anesthesiology Source Type: research
Accelerated fibrinolysis in cardiac surgery is infrequent given routine use of antifibrinolytic therapy to decrease risks of bleeding. However, in liver transplantation (LT), hyperfibrinolysis (HF) (>7.5% lysis in 30 minutes) may occur and can be identified in this and other clinical scenarios by point-of-care viscoelastic coagulation monitors, such as the Thrombelastograph (TEG) (Haemonetics, Braintree, MA).1,2 In addition to thrombocytopenia and alteration in platelet aggregation in patients with cirrhosis, detection of the effects of antithrombotic therapy has been reported with Platelet Mapping (PM), an adaptation o...
Source: Journal of Cardiothoracic and Vascular Anesthesia - Category: Anesthesiology Authors: Tags: Letter to the Editor Source Type: research
Publication date: Available online 17 December 2019Source: Best Practice &Research Clinical AnaesthesiologyAuthor(s): Ahmed Mukhtar, Ahmed Lotfy, Amr Hussein, Eman FouadAbstractThe interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from systemic circulation into splanchnic bed which decreases effective blood volume. Moreover, rapid volume loading in these patients has little impact on cardiac output because higher proportion of infused fluid is shifted to splanchnic ...
Source: Best Practice and Research Clinical Anaesthesiology - Category: Anesthesiology Source Type: research
ConclusionBased on low or very low levels of evidence, we did not find any association between restrictive fluid management strategies and AKI, but we observed possible protective effects of intraoperative restrictive fluid management strategies on other outcomes.Trial registrationPROSPERO (CRD42017054970); registered 18 May, 2017.
Source: Canadian Journal of Anesthesia - Category: Anesthesiology Source Type: research
Abstract Acquired fibrinogen deficiency is a major determinant of severe bleeding in different clinical conditions, including cardiac surgery, trauma, postpartum hemorrhage, liver surgery, and transplantation. The existing guidelines recommend to supplement fibrinogen in patients with severe bleeding when the fibrinogen concentration is
Source: Anesthesia and Analgesia - Category: Anesthesiology Authors: Tags: Anesth Analg Source Type: research
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 Sin...
Source: European Journal of Anaesthesiology - Category: Anesthesiology Tags: Coagulation Source Type: research
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