Perioperative hemostasis in hepatic surgery

Abstract

Coagulopathy in patients with liver cirrhosis is complex and can quickly decompensate to bleeding as well as to thrombosis. Both are associated with a worse outcome. However, routine coagulation tests, such as prothrombin time (PT) and the international normalized ratio (INR), are not able to discriminate between hypo- and hypercoagulability, nor are they able to predict the risk of bleeding in patients with liver dysfunction. Therefore, these tests cannot be used to guide hemostatic therapy in these patients, and prophylactic transfusion of fresh frozen plasma (FFP) and platelets, due to an increased INR or low platelet count, should be avoided. Accordingly, hemostatic interventions should only be performed in cases of clinically relevant bleeding. In contrast, thrombin generation assays in the presence of soluble thrombomodulin or Protac® – as well as viscoelastic tests (thromboelastometry/thromboelastography) – indicate that patients with liver dysfunction tend rather to hypercoagulability with its inherent risk of thrombosis. Furthermore, implementation of transfusion and coagulation management algorithms based on thromboelastometry has been shown to reduce transfusion requirements, transfusion-associated adverse events, and liver transplantation costs. Here, first-line, calculated, goal-directed therapy with fibrinogen prothrombin complex concentrate, guided by thromboelastometry, seems to be most effective without increasing the incidence of thrombotic/thromboembolic events. Notably, patients with liver dysfunction and increased INR are not “auto-anticoagulated.” Therefore, thromboprophylaxis should strongly be considered in patients with liver dysfunction, despite prolonged PT and increased INR.