Coagulation and Blood Transfusion Management

Patients with end-stage liver disease have profound alterations in their hemostatic system. Although routine diagnostic tests such as the prothrombin time or the platelet count suggest that these patients are at risk for bleeding, both clinical and laboratory evidence suggest that patients with liver disease are in hemostatic balance as a result of a concomitant decrease in pro- and anticoagulant factors. Therefore, routine correction of abnormal hemostatic parameters prior to liver transplantation is no longer indicated. Rather, administration of blood products should only be performed in those patients who are actively bleeding. Thromboelastography is used to assess clinical hemostasis and to guide therapy with pro- and anticoagulants. In addition, maintenance of physiologic body temperature, pH, and calcium levels as well as maintenance of a low central venous pressure appears vital in limiting blood loss during liver transplantation.