Detection and quantification of perioperative heparin-like effects by rotational thromboelastometry in living-donor liver transplant recipients: A prospective observational study

Khaled A Yassen; Emad K Refaat; Safaa M Helal; Ahmed A Metwally; Sherin D Youssef; Klaus Görlinger

doi:10.4103/joacp.joacp_521_21

Detection and quantification of perioperative heparin-like effects by rotational thromboelastometry in living-donor liver transplant recipients: A prospective observational study

J Anaesthesiol Clin Pharmacol. 2023 Apr-Jun;39(2):285-291. doi: 10.4103/joacp.joacp_521_21. Epub 2022 Jun 15.

Authors

Khaled A Yassen^{1

2}, Emad K Refaat¹, Safaa M Helal³, Ahmed A Metwally³, Sherin D Youssef⁴, Klaus Görlinger⁵

Affiliations

¹ Anaesthesia Department, National Liver Institute, Menoufia University, Shebeen El Kom City, Egypt.
² Anesthesia Unit/Surgery Department, College of Medicine, King Faisal University, Alhasa, Saudi Arabia.
³ Anaesthesia Departments, Faculty of Medicine, Menoufia University, Shebeen El Kom City, Egypt.
⁴ Anaesthesia Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt.
⁵ Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany; and Tem Innovations GmbH, Munich, Germany.

Abstract

Background and aims: Heparin-like effects (HLEs) can affect hemostasis during liver transplantation. The aim of this study was to assess the perioperative incidence and severity of HLE with rotational thromboelastometry (ROTEM) and activated partial thromboplastin time (aPTT).

Material and methods: ROTEM and aPTT were measured intraoperatively and on postoperative days (POD) 1, 3, and 7. HLE was identified if ROTEM INTEM/HEPTEM CT-ratio was >1.25 and severe forms of HLE when ratio was ≥2. Based on aPTT, HLE was defined when aPTT ratio was >1.25 (patient aPTT/control aPTT).

Results: Thirty-eight recipients were included. Variable degrees of HLE were detected by aPTT-ratio and INTEM/HEPTEM CT ratio. No significant correlation existed between both ratios. Based on INTEM/HEPTEM CT ratio, HLE was detected in 7/38 during anhepatic phase, 19/38 post-reperfusion, 10/38 on POD1, 4/38 on POD3, and 0/38 on POD7. Four cases of severe HLE were identified by INTEM/HEPTEM CT ratio only in the anhepatic phase. Postoperative infusion of unfractionated heparin led to mild-moderate HLE on POD1 and 3 as evident by both tests. Red blood cell and plasma transfusion were higher with severe HLE (1350 ± 191 ml and 3558 ± 1407 ml). Composite adverse outcome of any complication or death within 3 months for patients without HLE, mild-moderate HLE, and severe HLE as detected by ROTEM was 27.8%, 42.9%, and 66.7%, respectively.

Conclusion: INTEM/HEPTEM CT ratio was able to detect and quantify HLE as aPTT ratio. The ability of the INTEM/HEPTEM CT ratio to identify severe HLE earlier in the anhepatic phase needs to be studied in a larger population. HLE is self-limiting, but when identified in a severe form, it is associated with worse outcome.

Keywords: Blood coagulation; heparin-like effect; liver transplantation; thromboelastometry.