title: Coagulation defects do not predict blood product requirements during liver transplantation.
abstract: BACKGROUND
  In our experience, correction of coagulation defects with plasma transfusion does not decrease the need for intraoperative red blood cell (RBC) transfusions during liver transplantation. On the contrary, it leads to a hypervolemic state that result in increased blood loss. A previous study has shown that plasma transfusion has been associated with a decreased 1-year survival rate. The aim of this prospective study was to evaluate whether anesthesiologists could reduce RBC transfusion requirements during liver transplantation by eliminating plasma transfusion.
  
  
  METHODS
  Two hundred consecutive liver transplantations were prospectively studied over a 3-year period. Patients were divided into two groups: low starting international normalized ratio (INR) value <1.5 and high INR > or =1.5. Low central venous pressure was maintained in all patients before the anhepatic phase. Coagulation parameters were not corrected preoperatively or intraoperatively in the absence of uncontrollable bleeding. Phlebotomy and auto transfusion of blood salvaged were used following our protocol. Independent variables were analyzed in both univariate and multivariate fashion to find a link with RBC transfusions or decreased survival rate.
  
  
  RESULTS
  The mean number of intraoperative RBC units transfused was 0.3+/-0.8. Plasma, platelet, albumin, and cryoprecipitate were not transfused. In 81.5% of the patients, no blood product was used during their transplantation. The average final hemoglobin (Hb) value was 91.2+/-15.0 g/L. There were no differences in transfusional rate, final Hb, or bleeding between two groups (low or high INR values). The overall 1-year survival rate was 85.6%. Logistic regression showed that avoidance of plasma transfusion, phlebotomy, and starting Hb value were significantly linked to liver transplantation without RBC transfusion. The need for intraoperative RBC transfusion and Pugh's score were linked to the decreased 1-year survival rate.
  
  
  CONCLUSIONS
  The avoidance of plasma transfusion was associated with a decrease in RBC transfusions during liver transplantation. There was no link between coagulation defects and bleeding or RBC or plasma transfusions. Previous reports indicating that it is neither useful nor necessary to correct coagulation defects with plasma transfusion before liver transplantation seem further corroborated by this study. We believe that this work also supports the practice of lowering central venous pressure with phlebotomy to reduce blood loss, during liver dissection, without any deleterious effect.
authors.affiliation: Department of Anesthesiology, Service of Centre hospitalier de l'Université de Montréal, Hôpital St-Luc, Montréal, QC, Canada. luc.massicotte@umontreal.ca
authors.forename: Luc
authors.initials: L
authors.lastname: Massicotte
authors.forename: Danielle
authors.initials: D
authors.lastname: Beaulieu
authors.forename: Lynda
authors.initials: L
authors.lastname: Thibeault
authors.forename: Jean-Denis
authors.initials: JD
authors.lastname: Roy
authors.forename: Denis
authors.initials: D
authors.lastname: Marleau
authors.forename: Réal
authors.initials: R
authors.lastname: Lapointe
authors.forename: André
authors.initials: A
authors.lastname: Roy
mesh_terms: D000328:Adult; D000368:Aged; D001778:Blood Coagulation Disorders / Q000097:blood*; D016913:Blood Component Transfusion / Q000706:statistics & numerical data*; D003404:Creatinine / Q000097:blood; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D007432:Intraoperative Period; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010976:Platelet Count; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies
chemical_list: D003404:Creatinine