title: Coagulopathy after a liver resection: is it over diagnosed and over treated?
abstract: BACKGROUND
  Prothrombin time-international normalized ratio (PT-INR) is widely utilized to guide plasma therapy and initiation of thromboprophylaxis after a hepatectomy. Thrombelastography (TEG) monitors shear elasticity, which is sensitive to cellular and plasma components in blood, allowing for functional assessment of the life of the clot. The objective of this study was to prospectively compare PT-INR and TEG in liver resection patients.
  
  
  METHODS
  Forty patients were enrolled before undergoing an elective hepatectomy. Patients underwent a liver resection utilizing a low central venous pressure (CVP) anaesthetic technique and intermittent Pringle manoeuver. PT-INR and TEG were drawn prior to incision, post-operatively, and post-operative days 1, 3 and 5.
  
  
  RESULTS
  All post-operative PT-INR values increased significantly when compared with pre-operative PT-INR (P < 0.01). The time of onset to clot (R-value) decreased significantly at the post-operative time point (P = 0.04), consistent with a relative hypercoagulability. Subsequent R-values were not different compared with the pre-operative R-value. The strength of the clot (maximum amplitude, MA) was unchanged when comparing pre- and post-operative time points.
  
  
  CONCLUSIONS
  In spite of an elevation in PT-INR, patients undergoing a liver resection demonstrated a brief hypercoagulable state, followed by normal coagulation function based on TEG. These data call into question the practice of utilizing PT-INR to guide plasma transfusion and timing of prophylactic anticoagulation after a liver resection.
authors: Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Jeffrey S
authors: JS
authors: Barton
authors: Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Gordon M
authors: GM
authors: Riha
authors: Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Jerome A
authors: JA
authors: Differding
authors: Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Samantha J
authors: SJ
authors: Underwood
authors: Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Jodie L
authors: JL
authors: Curren
authors: Division of General Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Brett C
authors: BC
authors: Sheppard
authors: Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Rodney F
authors: RF
authors: Pommier
authors: Division of Liver and Pancreas Transplantation, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Susan L
authors: SL
authors: Orloff
authors: Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Martin A
authors: MA
authors: Schreiber
authors: Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
authors: Kevin G
authors: KG
authors: Billingsley
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000009:adverse effects*; D006801:Humans; D008107:Liver Diseases / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D011517:Prothrombin Time; D013916:Thrombelastography; D015912:Thrombolytic Therapy / Q000379:methods*; D013927:Thrombosis / Q000097:blood / Q000209:etiology* / Q000628:therapy