Current Hematological Concepts and Viscoelastic-Based Transfusion Practices During Liver Transplantation

Purpose: When the cascade model of coagulation was postulated in 1964, it convincingly explained the conventional tests of coagulation and their therapeutic applications for existing anticoagulants. But the conventional tests only tend to measure the procoagulant factors and not the anticoagulant factors present in the blood, as a result, the coagulation concept was updated to cell-based model in 2001. Despite these facts, the conventional tests are still used perioperatively in liver transplantation for blood product management, at the risk of causing over-transfusion and deleterious prothrombotic effects. This article reviews the current understanding of coagulation and suggests an improved method to manage intraoperative blood product replacement. Recent Findings: We set out to develop a diagnostic and dosing protocol based on viscoelastic tests, which more accurately reflect the dynamic interplay between pro and anticoagulants in the end-stage liver disease patient. This approach reduces the overtransfusion and resulting harm from excessive coagulation without increasing the risk of intraoperative bleeding. Conclusion: While we were successful in formulating a dosing regimen based on available literature and our own institutional practices for treating deficiencies of clotting factors and fibrinogen, more research is needed to arrive at a dosing regimen for platelets based on functional deficiency. © 2018, Springer Nature Switzerland AG.