Transfusion and coagulation management in liver transplantation

Table 3 Coagulopathy during transplantation

Stage	Coagulation abnormalities increasing bleeding	Other risk factors for bleeding	TEG
Dissection	Thrombocytopaenia Platelet function defects Increased nitric oxide and prostacyclin Low levels of factors II, V, VII, IX, X, XI Vitamin K deficiency Low levels of alpha 2 anti-plasmin, factor XIII, thrombin activatable fibrinolysis inhibitor Elevated t-PA Dysfibrinogenaemia	Surgical technical difficulty Portal hypertension Oesophago-gastric venous distension secondary to compression and vascular clamping	Prolonged R time Decreased alpha-angle Reduced MA
Anhepatic	Reduced coagulation factor synthesis Reduced clearance of t-PA	Duration greater than 45 min	Increased lysis
Reperfusion	‘‘Heparin like effect’’ Platelet entrapment in sinusoids of donor liver Reduction of all coagulation factors Decreased PAI-1 Decreased antifibrinolytic factors Hyper-fibrinolysis	Acidosis Hypothermia	Virtually ‘‘flat’’ native trace with prolonged R time and significantly reduced MA Heparinase trace required Lysis
Post reperfusion	Accelerated t-PA release Thrombocytopaenia (balanced by increased activation)	Delayed graft function	MA reduced

TEG: Thromboelastography; MA: Maximum amplitude; t-PA: Tissue plasminogen activator; PAI-1: Plasminogen activator inhibitor.