Dr. Harshal Rajekar MS MRCS DNBConsultant Hepatobiliary, GI and

Transplant SurgeonRuby Hall Clinic, Pune.

Liver transplantation (OLT) is the replacement of a diseased liver with a healthy liver.

The operative procedure is extensive, complex, and technically challenging, with multiple vascular transections and anastomoses.

In addition, the liver is an extremely vascular organ and extensive bleeding can occur in patients with portal hypertension due to ESLD.

Historically, significant blood loss at the time of liver transplantation.

Treated with large autologous transfusions of packed RBCs, FFP, platelets & cryoppt.

Drugs are given along with the blood products, to help correct metabolic and coagulation abnormalities.

Portal Hypertension. Solid Organ. Portal clamping. Coagulopathy. Splenic sequestration. Liver failure and thrombopoetin.

In acute or chronic liver failure – deficiency of clotting factors II (prothrombin), VII, IX, and X.

Therefore coagulopathy - prolonged prothrombin time (PT).

Prolonged activated partial thromboplastin time (aPTT).

Cholestasis leads to decreased synthesis of vitamin K–dependent clotting factors (II, VII, IX, and X), further contributing to abnormal clotting.

In advanced liver failure, this abnormality may not be correctable, even with oral or parenteral vitamin K administration.

Thrombocytopenia is another common problem in cirrhotic patients.

The liver is the primary site of thrombopoietin synthesis.

In addition, splenomegaly caused by portal hypertension leads to platelet sequestration and destruction.

Patients with end-stage liver disease (ESLD) demonstrate increased fibrinolytic activity. This results in a low-grade disseminated intravascular coagulation–like picture.

HPB surgery, surgery on the Liver:-

Increase in portal pressure. Release of NO due to induction of

NOS in sup. mesenteric artery. DIC like picture. Peripheral vasodilation.

PT – INR Fibrinogen level. Platelet count. TEG.

Renal function tests and measure renal dysfunction.

H/o prior transfusion and recent GI bleed

Pre-op TEG Qualitative platelet function. Aim to maintain INR < 1.5 – 1.6. Aim for platelet count around 50,000. Try to obtain fibrinogen level of 2.

Optimize serum Ca++, optimize ABG, optimize temperature, use of tranexamic acid.

Liver transplantation surgery may be divided into 3 stages.

Stage I (preanhepatic period) begins with dissection of the inflow and outflow vascular structures of the liver and ends with removal of the diseased organ.

Stage II (anhepatic phase) begins with implantation of the donor liver and ends with reperfusion of the new organ.

Stage III (reperfusion and postreperfusion period) begins with reperfusion of the grafted liver and ends with completion of the surgery.

- Preexisting abnormalities of

clotting, platelets, and fibrinolysis compound the problem.

Addressing these abnormalities is crucial.

Usually start a tranexamic acid infusion.

Correct Calcium. Maintain body temperature.

Avoid transfusion of platelets and PRBC at the beginning

TEG to guide therapy

Blood loss in stage I occurs mainly from transection of the fragile collateral vessels that develop as a result of portal hypertension.

In addition, extensive bleeding may occur from raw areas remaining after liver explantation.

Preexisting abnormalities of clotting, platelets, and fibrinolysis compound the problem.

DIC

Clotting function is assessed during liver transplantation with the standard coagulation tests (ie, PT, aPTT, fibrinogen level).

In addition, the thromboelastogram and coagulation and

Platelet function analyzer (eg, Sonoclot) are used.

Fibrinolysis may be a problem during the anhepatic or postanhepatic phase of OLT.

d/t diminished uptake of t-PA, accumulation of fibrinolytic activators, and enhanced release of t-PA from the donor liver after reperfusion.

Additionally, alpha-2 antiplasmin, the principal inhibitor of plasmin and plasminogen activity during this phase, is decreased.

Important variables affecting transfusion requirements

the severity of disease or Child classification,

preoperative PT, history of abdominal operations, and factor V levels. the preoperative hematocrit value, use of the piggyback transplantation

method, and operative time. Previous SBP

Aprotinin EACA – epsilon amino caprioic

acid. Tranexamic acid.

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