Transfusional optimization in liver transplant using viscoelastic test guided therapy. / Optimización transfusional en el trasplante de hígado usando terapia guiada por pruebas viscoelásticas.

BACKGROUND: Assess the reduction of packed red blood cells (PRBCs) transfusion in liver transplantation (LT) after the introduction of the thromboelastometry as intraoperative coagulation monitor. METHODS: We conducted a retrospective cohort study (n=92), randomized into two groups: groupA (control), in whom transfusion therapy was based on conventional laboratory tests (CLT), and groupB (ROTEM), whose blood transfusion was performed as protocolized algorithms, guided by thromboelastometry (ROTEM). We analyzed packed red blood cells (PRBCs) units, transfused units of fresh frozen plasma (FFP), platelets units, fibrinogen and tranexamic acid. We used the chi square test for the comparison of proportions and Student's t test to compare means when the distribution was normal. Otherwise, Mann-Whitney U test was performed. RESULTS: In groupA 84.8% of patients required transfusion of PRBCs, with a median (IQR) of 4 (1.5-6), compared with 67.4% in groupB with a median (IQR) of 2 (0-4) (P<.05). We also found differences in the following variables: FFP transfusion rate was 84.8% with a median (IQR) of 5 (2-12) IU in groupA and 56.5% (median (IQR) of 1 (0-4.5) in B (P<.001) and in the fibrinogen administration, that was 6.5% in groupA and 34.8% in groupB (P<.01). Backward stepwise logistic regression model showed associations between the clamping time, the preoperative hemoglobin, the portal hypertension (PHT) and being or not in the treatment group and the need for perioperative transfusion. We didn't find significant differences in the incidence of complication during the early postoperative period between the two groups. CONCLUSIONS: The introduction of thromboelastometry (ROTEM) measurements in hemostatic therapy algorithms reduces the transfusion rate of FFP and PRBCs during liver transplantation. The using of ROTEM derived thresholds leads to detecting higher requirements of fibrinogen compared to conventional laboratory tests.

Predicting fluid responsiveness in patients undergoing orthotopic liver transplantation: effects on intraoperative blood transfusion and postoperative complications.

OBJECTIVE: To test the hypothesis that the restrictive volume therapy decreases blood transfusion requirement during liver orthotopic transplantation (OLT) without increasing acute renal complications and hospital length stay. MATERIAL AND METHODS: We conducted a retrospective cohort study (n = 89), randomized into 2 groups: A (liberal fluid strategy) and B (restrictive therapy). We analyzed packed red blood cells (PRBCs) units, transfused units of fresh frozen plasma (FFP), colloids, crystalloids, perioperative renal function, and hospital length stay. For comparison of proportions, we used the χ(2) test and Student t test to compare means (parametric). A logistic regression model was constructed to evaluate the association of all these variables with probability of PRBCs transfusion. RESULTS: In group A, 88.4% of patients required intraoperative transfusion of PRBCs, with a mean of 8.5 ± 7.02 IU, compared with 82.2% in group B with a mean of 5.02 ± 4.5 IU (P < .001). We also found differences in the following variables: FFP transfusion rate was 95.3% (mean, 15.02 ± 8.2 IU) in group A and 75.6% (mean, 8.7 ± 6.04 IU) in B (P < .001). The amount of colloid was 50% (mean, 692.8 ± 409.6 mL) in group A and 28.9% (mean, 607.6 ± 316.7 mL) in B (P = .032). Platelet concentrates transfusion was 79.1% (mean, 2.05 ± 1.1 IU) in group A and 51.1% (mean, 2.0 ± 1.08 IU) in B (P = .014). As an important effect of restrictive fluid therapy, renal function was assessed; no differences in mean creatinine or acute renal failure in the immediate postoperative period were observed. There was no difference in hospital length stay. Logistic regression modelling identified 3 variables as significant predictors of transfusion: Fluid administration policy, preoperative hemoglobin and FFP units transfused. Furthermore, an increase of preoperative hemoglobin is associated with a lesser probability of transfusion. CONCLUSIONS: These results show that fluid restriction management for OLT decreased blood products requirements, especially FFP. This could suggest that liberal fluid management may aggravate, rather than prevent, bleeding in these patients. We did observed any no difference in failure of renal function.