Department of General, Visceral, and Transplant Surgery.
Department of Anesthesiology and Critical Care, University Hospital Essen, Hufelandstraße 55, 45259 Essen, Germany.
Br J Anaesth. 2017 Sep 1;119(3):402-410. doi: 10.1093/bja/aex122.
Perioperative bleeding remains a major challenge in liver transplantation. We aimed to compare standard laboratory tests with thromboelastometry (ROTEM ® ) with regard to their ability to predict postoperative non-surgical bleeding.
Data from 243 adult liver transplant recipients from January 2012 to May 2014 were evaluated retrospectively. Upon admission to the intensive care unit, coagulation status was assessed using standard laboratory tests [prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen concentration, and platelet count] and ROTEM ® whole blood coagulation assays. Bleeding was defined as transfusion of ≥ 3 units of red blood cells or reoperation for non-surgical bleeding within 48 h after transplantation. Coagulation test results were analysed using receiver operating characteristics (ROC) in order to identify variables predictive of postoperative bleeding. Coagulation management was based on ROTEM ® -guided factor concentrate treatment.
The overall incidence of bleeding was 12.3% ( n =30). Twenty-three (9.5%) patients underwent reoperation and seven (2.9%) received ≥3 units of red blood cells and non-operative management. Standard laboratory tests predictive of postoperative bleeding were aPTT and PT [area under the ROC curve (AUC) 0.688 and 0.623, respectively]. Tests predictive of bleeding with ROTEM ® were CT EXTEM , CFT INTEM , A10 FIBTEM , and MCF FIBTEM , with AUCs of 0.682, 0.615, 0.615, and 0.611, respectively. Fibrinogen concentration, platelet count, and other ROTEM ® variables failed to demonstrate predictive value for postoperative bleeding (AUC <0.6). Dialysis-dependent kidney failure, 30 day mortality, and median model for endstage liver disease score were all significantly higher in bleeding patients.
Although both postoperative standard laboratory tests and ROTEM ® assays could identify patients at risk for postoperative bleeding, ROTEM ® assays demonstrated a greater predictive value for impaired fibrinogen polymerization-related coagulopathy.
围手术期出血仍然是肝移植的主要挑战。我们旨在比较标准实验室检查与血栓弹性描记术（ROTEM ® ）在预测术后非手术性出血方面的能力。
回顾性分析 2012 年 1 月至 2014 年 5 月期间 243 例成人肝移植受者的数据。入住重症监护病房时，使用标准实验室检查[凝血酶原时间（PT）、活化部分凝血活酶时间（aPTT）、纤维蛋白原浓度和血小板计数]和 ROTEM ® 全血凝血检测评估凝血状态。出血定义为术后 48 小时内输注≥3 单位红细胞或因非手术性出血再次手术。使用受试者工作特征（ROC）分析凝血试验结果，以确定预测术后出血的变量。凝血管理基于 ROTEM ® 指导的因子浓缩物治疗。
总的出血发生率为 12.3%（n=30）。23 例（9.5%）患者再次手术，7 例（2.9%）患者接受≥3 单位红细胞和非手术治疗。预测术后出血的标准实验室检查为 aPTT 和 PT[ROC 曲线下面积（AUC）分别为 0.688 和 0.623]。ROTEM ® 预测出血的检测为 CT EXTEM 、CFT INTEM 、A10 FIBTEM 和 MCF FIBTEM，AUC 分别为 0.682、0.615、0.615 和 0.611。纤维蛋白原浓度、血小板计数和其他 ROTEM ® 变量未能显示术后出血的预测价值（AUC<0.6）。出血患者的透析依赖的肾功能衰竭、30 天死亡率和中位终末期肝病模型评分均显著升高。
尽管术后标准实验室检查和 ROTEM ® 检测都可以识别术后出血风险患者，但 ROTEM ® 检测对纤维蛋白原聚合相关凝血障碍的预测价值更大。
