Vitamin K antagonist therapy and liver transplantation: two cases managed without normalizing the international normalized ratio.

Guidelines for surgery in patients treated with vitamin K antagonist recommends to correct international normalized ratio (INR), although they do not focus on liver transplantation candidates. We report two patients treated with vitamin K antagonist, monitored by thromboelastometry during liver transplantation. Case 1: basal INR was 3.15. Extem coagulation time was 83 s and maxim clot firmness was 60 mm. The surgical procedure did not show bleeding. Two red blood cells were transfused and no other blood products were administered. Last INR was 3.17. Case 2: basal INR was 2.79. A thrombocytopenia of 58 000/mm was detected. Extem coagulation time was 176 s, and maxim clot firmness was 40 mm. Fibtem maxim clot firmness was 11 mm. The surgical procedure did not show bleeding. No blood product was administered. Last INR was 2.1. Although thromboelastometry did not correlate with INR, monitoring of the coagulation using thromboelastometry in combination with surgery helped to conduct hemostatic corrections.

Hemostasis and coagulation monitoring and management during liver transplantation.

PURPOSE OF REVIEW: The objective of this review is to evaluate the present state of nonpharmacological measures, pharmacological measures applied to reduce bleeding and perioperative blood products management during orthotopic liver transplantation. RECENT FINDINGS: Recent studies improve the knowledge in the hemostatic response in cirrhotic patients such as thrombin generation and platelet adhesion due to elevated levels of von Willebrand factor. Restrictive fluid therapy is an important measure to avoid hemodilution and so bleeding. Prophylaxis with antifibrinolytics is being questioned for the risk of thrombosis. Correction of coagulation defects with fresh frozen plasma has not reduced blood loss, and it has been related to worse outcome. Also, platelets administration has a negative effect in the outcome. SUMMARY: In order to maintain hemostatic system in compensated cirrhotic patient, every effort we do to improve it must consider not to imbalance it resulting in thrombi-hemorrhagic events. Pharmacological measures must be based on their clinical evidence. Identification of high risk bleeding patients would help in developing coagulation guidelines.