olt without blood
TRANSCRIPT
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 1/41
LIVER TRANSPLANTATIONLIVER TRANSPLANTATIONWITHOUT BLOOD LOSSWITHOUT BLOOD LOSS --
Myth or Reality
Odisseeva E., Vladov N*., Petrov N.
Department of Anesthesiology and Intensive Care
*Clinic of Hepatobiliary, Pancreatic and Transplant Surgery
Military Medical Academy ² Sofia
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 2/41
Objectives: The mythObjectives: The myth ² ² Liver transplantationLiver transplantation
is associated with high blood loss and largeis associated with high blood loss and largeamount of blood transfusions is neededamount of blood transfusions is needed
y The patient with liver disease and cirrhosis
usually bleeds more in the operating roomdue to coagulopathy
y We believe we must correct coagulopathy
by transfusion of blood productsy It· unusual ² liver transplantation without
transfusion of blood products
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 3/41
The patient with liver disease and cirrhosisThe patient with liver disease and cirrhosis
usually bleeds more in the operating room ???usually bleeds more in the operating room ???
y Check for preexisting coagulationabnormalities:
x PT/INR
x APTT
x Fibrinogen
x Platelet count
y We believe we must correct them by
transfusion of blood products:x Fresh frozen plasma
x Protrombin complex
x Cryoprecipitate
x Platelet concentrates
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 4/41
TransfusionTransfusion of fresh frozen plasma in critically illof fresh frozen plasma in critically illsurgical patients is associated with an increased risk of surgical patients is associated with an increased risk of infectioninfection..SaraniSarani B et al. Division of B et al. Division of TraumatologyTraumatology and Surgical Critical Care, Department of Surgery,and Surgical Critical Care, Department of Surgery,
University of Pennsylvania, School of Medicine, Philadelphia, PA, USA. [email protected] of Pennsylvania, School of Medicine, Philadelphia, PA, USA. [email protected]
complication relative risk
ventilator-associated pneumonia with shock 5.42 ( 2.73-10.74)
ventilator-associated pneumonia without shock 1.97 (1.03-3.78)bloodstream infection with shock 3.35 (1.69-6.64)
undifferentiated septic shock 3.22 (1.84-5.61).
all infections 2.99 (2.28-3.93)
The association between fresh frozen plasma aplicationand infectious complications remainedsignificant in the multivariate model, with an odds ratio of infection per unit of fresh frozen
plasma transfused equal to 1.039 (1.013-1.067).This odds ratio resembled that noted for each
unit of packed red blood cells, 1.074 (1.043-1.106).
CONCLUSIONS: Transfusion of fresh frozen plasma is associated with an increased risk of
infections in critically ill patients.
PMID: 18379235 [PubMed - indexed for MEDLINE]
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 6/41
Marieke T. de Boer, MD* et al.AnesthAnalg 2008;106:32²44)No. 1, January 2008
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 7/41
15% increase in
6-month mortality 33% increase in
6- month
mortality
Marieke T. de Boer, MD* et al.AnesthAnalg 2008;106:32²44)No. 1, January 2008
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 8/41
Correction with Blood ProductsCorrection with Blood Products
y Efficiency has never been proven
y Correction of prolonged INR requiresseveral units of FFP
y Transfusion of blood components isassociated with important side effects:
x Viral and bacterial transmissions
x Immunosuppresion ² TRIM
x Increased rate of infectious complications
x TRALI
x TACO ² acute fluid overload ( i.e. FFP)
x etc
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 9/41
Key question is:Key question is:
y What is the best strategy to minimizeblood loss in patients undergoing liver
transplantation?Should we correct or to contract ?
Liberal infusion versus fluid restriction?
Is there evidence for best practice?
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 10/41
Is Haemostatic Function Really ThatIs Haemostatic Function Really That
AAbnormal in Cirrhotic Patientsbnormal in Cirrhotic Patientsy Primary hemostasis
x Platelets ² von Willebrand Factor ² endothelium
y Secondary hemostasis
x Plasmatic coagulation / Thrombin
generation
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 11/41
Definition of Definition of HemostasisHemostasis
Bleeding to
Death
Clotting to
Death
Haemostasis : ́ Live in the Balance ́
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 12/41
Procoagulant
activity
Fiblinolytic
activity
Anticoagulant
activity
Antifibrinolityc
activity
NormalHemostasis
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 13/41
The Concept of RebalancedThe Concept of Rebalanced HemostasisHemostasisinin PatientsPatients withwith LiverLiver DiseaseDisease
Haemostatic changes
impairing haemostasis
Haemostatic changes
promoting haemostasis
Low platelet count
Impaired platelet functionand plateletvessel wall interaction
Primary hemostasis levels of vWF
Decreased levels of ADAMTS-13
Factor II, V, VII, IX, X, XIQuantitative and qualitativeabnormalities in fibrinogen
Secondary hemostasis
Elevated levels of FVIII, Protein C, protein S, protein Z,
AT(III), heparin-CoFII,2-
macroglobulin
2-anti-plasmin, TAFI, HRG
t-PA (not balanced by PAI-
1 levels)Fibrinolysis
plasminogen
From T. Lismanet al. J Hepatol 2002;37:280-7
Rebalansing
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 14/41
The Concept of RebalancedThe Concept of Rebalanced HemostasisHemostasisin Patients with Liver Diseasein Patients with Liver Disease ² ²
PrimaryPrimary hemostasishemostasis
Low platelet count,Impaired plateletfunction and
platelet vessel wallinteraction
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 15/41
FVIII and vWF
Low platelet count,
Impaired plateletfunction and
platelet vessel wallinteraction
TheThe ConseptConsept of Rebalancedof Rebalanced HemostasisHemostasisin Patients with Liver Diseasein Patients with Liver Disease ² ²
PrimaryPrimary hemostasishemostasis
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 16/41
The Concept of RebalancedThe Concept of Rebalanced HemostasisHemostasisin Patients with Liver Diseasein Patients with Liver Disease ² ²
SecondarySecondary hemostasishemostasis
Procoagulants
Factor II, V, VII, IX, X, XIQuantitative and qualitative
abnormalities in fibrinogen
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 17/41
Procoagulants Anticoagulants
Factor II, V, VII, IX, X, XIQuantitative and qualitative
abnormalities in fibrinogen
Factor VIII Protein C,
protein S, protein Z,
AT(III),
heparin-CoFII, 2-macroglobulin
Generation of thrombin is normal in cirrhosis
The Concept of RebalancedThe Concept of Rebalanced HemostasisHemostasisin Patients with Liver Diseasein Patients with Liver Disease ² ²
SecondarySecondary hemostasishemostasis
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 18/41
y The overall hemostatic function in
patients with cirrhosis seems less
disturbed than what is traditionally
assumed on coagulation test and
platelet count
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 21/41
ThromboelastogramThromboelastogram(TEG)(TEG)
Global analysis of whole
coagulation process
Sensitive to activators andinhibitors
Visual assessment of clotstrength & stability
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 22/41
Preoperative coagulation Profile andPreoperative coagulation Profile andbleeding during Liver Transplantationbleeding during Liver Transplantation
y Conventional coagulation tests are a poorpredictor of blood loss during LT
Reyle-Hahn I Rossaint. Liver TransplSurg 1997
Steib et al. Can J Anaesth 2001Massicotte et al. Transplantation 2008
y Conventional coagulation tests do not
describe the really state of haemostasis inthe patients with LD.
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 23/41
y Is it possible other factors to be moreimportant determinants of bleeding than
changes in coagulation?
y What is the evidence that volume
restriction is more effective than
correction
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 24/41
Characteristic of Circulation inCharacteristic of Circulation inPatients with CirrhosisPatients with Cirrhosisy Hyperdynamic circulation
High cardiac output
Low peripheral resistance
y
Relatively fluid overloaded Sodium retention
Diminished renal function
Ascites
y Altered blood volume distribution Pooling of blood in the splanchnic circulation
Portal hypertention
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 25/41
CollateralsDilated vessels
High hydrostatic pressure
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 26/41
CollateralsDilated vessels
High hydrostatic pressure
Bleeding
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 27/41
y Every Liver Surgeon can Tell you That
Portal Hypertention is An Important
Determinant of blood loss
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 28/41
Low CVP < 5 mm HgLow CVP < 5 mm Hg
y Anesthesiologists have proved it :
Liverpool UK - M.Johnson , R.Mannar 1998
2 x CVP 9 x Hemorrhage
CVP < 6 mmHg 6 ² 12 mmHg CVP >12 mmHg
303 ml 1259 ml 2703 ml
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 29/41
Since 2008Since 2008
y Preoperative ² we don·t correct verystrictly the PT and aPTT with transfusion
of FFP
y Platelets transfusion-- if Plts< 50 000 andin a case of acute bleeding
y In the phase of dissection ² low CVP
y Fluid Restriction ² very strict balancey Restoration of the blood volume before
reperfusion
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 30/41
Fluid Restriction = Volume ContractionFluid Restriction = Volume Contraction
y Transfusion triger ² Hb<80 g/l
y Transfusion of crystalloids - 4-5 ml/kg/h
y Transfusion of coloids ² max. 10 ml/kg
y Transfusion of FFP = Volume overload
y PCC ² when coagulopathy require quick
reversal without volume overload
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 31/41
Military Medical AcademyMilitary Medical Academy
y April 2007 - August 2010
y 23 liver transplantations
y Average age - 43,7 years
y 18 male , 5 female
Year 2007 2008 2009 2010
Pts 5 4 7 7
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 32/41
ResultsResults -- Blood loss mlBlood loss ml
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 33/41
ResultsResults -- Blood loss mlBlood loss ml
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 34/41
ResultsResults -- Transfusion of RBC mlTransfusion of RBC ml
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 35/41
ResultsResults -- Reinfusion mlReinfusion ml
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 36/41
PatientsPatients -- Child C in %Child C in %
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 37/41
LT without blood transfusionLT without blood transfusion
Year 2007 2008 2009 2010
Pts 1 (20%) 1 (25%) 5 (71,4%) 5 (71,4%)
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 38/41
ConclusionsConclusions
y Abnormal coagulation tests do notpredict bleeding
y The impaired tests may results in
satisfactory overall hemostatic function
y Preoperative correction of abnormal
coagulation tests with blood product is
ineffectivey In fact it worsens the bleeding tendency
8/8/2019 OLT Without Blood
http://slidepdf.com/reader/full/olt-without-blood 39/41
ConclusionsConclusions
y Volume restriction instead of correctionof coagulation tests with large volumes of
FFP is more effective in reducing bleeding
y In cirrhotics, major surgery can be
performed safely without blood product
transfusions ( RBC, FFP, Plts)