2.dani kaogulacije, Zagreb 2019.

1. Coagulation mamagement in
paediatric liver
transplantation
Karolina Režek Tomašić, dr.med.
Dr.sc.Tajana Zah Bogović, dr. med.

2. Dr. Thomas Starzl, 1963
Attempted the first human liver transplant in a critically ill child
with biliary atresia
Child bled to deth
Starzl TE, Marchioro TL,.Homotransplantation of the liver in humans.Surg Gynecol Obstet 1963; 117: 659–76.

3. Surgical blood loss has greatly decreased, largely due to changes
in surgical technique andd intra-operative fluid management,
rather than changes in coagulation replacement
Emre S, Umman V, Cimsit B, Rosencrantz R. Current concepts in pediatric liver
transplantation. Mt Sinai J Med 2012; 79: 199–213.

4. < 1y 29%
1-5y 38%
6-10y 14%
11-17y 19%
US Department of Health and Human Services HRaSA. OPTN/
SRTR Annual Report. 2011.
Age distribution

5. -our understanding of hemostasis in liver
failure are from adult patients
- pediatric population has not been carefully
studied
-the causes of liver failure in children are
different than adults
Raffini L, Witmer C. Pediatric transplantation: managing bleeding. J Thromb Haemost 2015; 13 (Suppl. 1): S362–S9.

6. LIVER FAILURE
CARDIOVASCULAR
SYSTEM
↑ HR
↑ CO
↑ stroke volume
↓SVR
↓ blood pressure
KIDNEYS
Oliguria- prerenal
hepatorenal syndrome
GI SYSTEM
malnutrition
portal hypertension
slow gastric empting
oesophageal varices
ascites
hypoalbuminemia
altered drug metabolism

7. Anemia
Reduced plasma concetrations of procoagulant clotting factors and
anticoagulant proteins
vitamin K deficiency (infants)
thrombocytopenia ( hypersplenism, reduced synthesis of
thrombopoetin)
↑ von Wilebrand antigen (preserves platelet adhesion)
↓synthesis of ADAMTS13
↑Factor VIII
fibrinolysis ↑↓
Acute liver failure: more severe reductions in coagulation proteins
less likely to be thrombocytopenic
higher risk for procedural bleeding
Chronic liver disease: more time for compensatory mechnisms to
develop
Lisman T, Porte RJ. Rebalanced hemostasis in patients with liverdisease: evidence and clinical
consequences. Blood 2010; 116:878–85.

8. PRETRANSPLANT
Vitamin K
Reduction of gastric acid
PRBC
FFP (20-40ml/kg)
Cryoprecipitate
Platelets(> 50x10*9)
Treat underlying disorders (infection, renal failure)
Vasoactive drugs

10. DURING TRANSPLANT
Children are at higher risk than adults for massive
transfusion
Infants (compared to older children)
Prior abdominal surgery (Kasai procedure)
Reduced size grafts
Anatomy
Blood loss: 4-586ml/kg
Emre S, Umman V, Cimsit B, Rosencrantz R. Current concepts in pediatric liver transplantation. Mt Sinai J Med 2012; 79: 199–213.

11. PREANHEPATIC STAGE
hypovolemia and hypotension
massive bleeding +coagulopathy
massive transfusion
inotropes, vazopressors
normothermia
diuresis

12. ANHEPATIC STAGE
hypotension
hypoperfusion
impared renal perfusion
NO liver
bleeding
(fibrinolysis-ROTEM-antifibrinolytic drugs)

13. NEOHEPATIC STAGE
Reperfusion syndrome
Acidosis
Hyperkalemia
Vasodialtation - hypotension
hypothermia+fibrinolysis - bleeding

14. Point of care tests (ROTEM..)
Laboratory tests
Use of topical agents at the resection surface

15. R.T. 11 m.o., 8.5kg, Retransplantation
Blood volume – 700ml
Kassai procedure 3.m.o.
Liver transplantation 6 m.o.
Multiple revisions – necrotic liver; early stage of chronic liver rejection
Septic - antibiotic therapy
Inotrope – hypotension
Received multiple doses of RCP, FFP, fibrinogen,
Diuresis was stimulated
Prior to surgery
E 3,4x10*12, Hb 100g/L, Htc 0,29, Lkc 0,9 x10*9/L, Trc 53, PV 0,39,
INR 1,81
APTV 42, Fibr 1,4 g/L, AT 60%, ureja 21, kreatinin 23
Bilirubin 426 mcmol/L

16. Bleeding from the beggining of surgery
After 7 h of surgery at the beggining of neohepatic stage;
PRBC 10 U FFP 9 U, Platelets 2U, Fibrinogen 800mg, PCC 500 i.j.
Inotrope + vaspressor

17. Problem with anastomosis of hepatal veins,
Massive surgical bleeding…
Time: 14h
Overall: PRBC 44 U, FFP 36 U, platelets 12U, PCC 2500i.j.,
fibrinogen 5g, atenativ 500 i.j. Novoseven 3,7mg,
Cell Saver 1950ml
44U = 11L = 15 x patient blood volume = 1290ml/kg