J. T. Graff1, V. K. Dhar1, C. Wakefield1, A. R. Cortez1, M. C. Cuffy1, M. D. Goodman1, S. A. Shah1 1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA
Introduction: Thromboelastography (TEG) has been shown to provide an accurate assessment of patients’ global coagulopathy and hemostatic function. While use of TEG has grown within the field of liver transplantation (LT), the relative importance of TEG values obtained at various stages of the operation and their association with outcomes remain unknown. Our goal was to assess the prevalence of TEG-based coagulopathy in patients undergoing LT, and determine whether preoperative TEG is predictive of transfusion requirements during LT.
Methods: An IRB approved, retrospective review of 380 consecutive LTs between January 2013 and May 2017 was performed. TEGs obtained during the preoperative, anhepatic, neohepatic, and initial postoperative phases were evaluated. Patients with incomplete data were excluded from the analysis, resulting in a study cohort of 110 patients. TEGs were categorized as either hypocoagulabe, hypercoagulable, or normal using a previously described composite measure of R time, k time, alpha angle, and maximum amplitude. Perioperative outcomes including transfusion requirements, need for temporary abdominal closure, and rates of reoperation for bleeding were evaluated.
Results: Of patients undergoing LT, 11.8% were hypocoagulable, 22.7% were hypercoagulable, and 65.5% were normal at the start of the operation. 46.4% of patients finished the operation in a different category of coagulation from which they started. Of patients starting LT hypocoagulable, 15.4% finished hypocoagulable, none finished hypercoagulable, and 84.6% finished normal. Patients with hypocoagulable preoperative TEGs were found to require more units of pRBC (12 vs. 6 vs. 6, p=0.04), FFP (24 vs. 13 vs. 8, p<0.01), cryoprecipitate (4 vs. 2 vs. 1, p<0.01), platelets (4 vs. 2 vs. 1, p <0.01), and cell saver (4.6 liters vs. 2.8 vs. 1.9, p<0.01) during LT compared to those with normal or hypercoagulable preoperative TEGs. Despite these higher transfusion requirements, there were no significant differences in rate of temporary abdominal closure, unplanned reoperation, ICU length of stay, or 30-day readmission (all p > 0.05) between patients with hypocoagulable, hypercoagulable, or normal preoperative TEGs.
Conclusion: Preoperative thromboelastography may be predictive of transfusion requirements during LT. By consistently evaluating the preoperative TEG, surgeons can identify patients who may be at higher risk for intraoperative coagulopathy and require increased perioperative resource utilization.