Minimizing Blood Loss in Recipient Surgery

Abstract

Interventions to reduce blood loss during Orthotopic Liver Transplant (OLT) have been surgical, anaesthesia-related and pharmacological. Intraoperative blood loss is a predictor of perioperative outcome following liver resection and transplantation and may have an effect on short-term and long-term survival. The liver plays a central role in the haemostatic system as it synthesizes the majority of coagulation factors and proteins involved in fibrinolysis. Although anticoagulant factors are decreased as well, blood loss during orthotopic liver transplantation can still be excessive in view of interplay between multiple factors. In patients with cirrhosis, the synthesis of coagulation factors can fall short, reflected by a prolonged prothrombin time. Patients undergoing orthotopic liver transplantation are at high risk of bleeding complications. Several authors have shown that thromboelastography (TEG)-based coagulation management and the administration of fibrinogen concentrate reduce the need for blood transfusion. The reduction in blood loss has also led to the successful transplantation of livers in Jehovah’s witnesses. Timely prevention and identification of “triangle of death” (hypothermia, acidosis and coagulopathy) play an important role in reducing blood loss. It is well known that blood transfusions are associated with an increased risk of postoperative complications, such as infections, pulmonary complications, protracted recovery and a higher rate of reoperations. Blood loss during orthotopic liver transplantation is currently managed by transfusion of red blood cell concentrates, platelet concentrates, fresh frozen plasma and fibrinogen concentrate. Increasing experience and improvements in surgical technique, anaesthesia care and better graft preservation methods have contributed to a steady decrease in blood transfusion requirements in most liver transplant programmes.