**4. Conclusion**

**3.3. Coagulation management**

222 Organ Donation and Transplantation - Current Status and Future Challenges

anticoagulant factors.

• maintaining a low CVP,

• use of antifibrinolytic agents,

• use of recombinant activated factor 7,

phases are specific for each phase:

• use of point of care tests for transfusion guidance.

the diagnosis and management of hyperfibrinolysis.

released in the circulation as inefficient.

the liver graft is viable.

[50].

(viscoelastic tests) are recommended [49].

Cirrhotic patients have been regarded as having a high risk of bleeding due to standard coagulation test abnormalities caused by cirrhotic coagulopathy. Recent studies have shown that

Standard coagulation tests (prothrombin time, INR and activated partial thromboplastin time (aPTT)) reveal the deficit of procoagulant factors without showing the status of the

In order to have an optimal view regarding cirrhotic coagulopathy, global coagulation tests

Intraoperative blood transfusion has a negative impact on patient outcome. Intraoperative packed red cells and platelet transfusion are independent predictors of 1 year mortality

The most important coagulation problems that can appear during the three transplant

• Preanhepatic phase: bleeding occurs due to extensive dissection, collateral circulation and portal hypertension. Maintaining a normal volemic status may lead to dilutional coagulopathy and thrombocytopaenia [51]. A low CVP must be maintained in this phase. Cell

• Anhepatic phase: between clamping hepatic inflow and before graft reperfusion. Usually, minimal bleeding takes place here, but the risk exists. Platelets and coagulation factors are low due to loss and consumption from the previous phase. Synthesis and liver clearance do not exist. An increase in the release of tPA from endothelial cells and the absence of hepatic clearance can lead to hyperfibrinolysis and bleeding. Viscoelastic tests are mandatory for

• Neohepatic phase: bleeding can occur due to surgical problems or haemostatic abnormalities. Usually, hypothermia, metabolic acidosis and hypocalcaemia must be corrected before any further decision is taken. Platelets are seized in the liver graft after reperfusion causing important thrombocytopaenia. Some platelets are partially activated in the liver graft and

Hyperfibrinolysis can often appear during liver transplantation, but is self-limited as long as

saver can also be used after evacuation of ascites and before biliary anastomosis.

There are a few measures that can decrease the need of blood transfusion:

bleeding episodes are caused by vascular abnormalities and portal hypertension [48].

Anaesthesia for liver transplantation is one of the most difficult anaesthesias. This is due to the haemodynamic problems that can occur in the intraoperative, related both to the status of the patient (cardiomyopathy of the cirrhosis, etc.) and to the surgical moments (bleeding and reperfusion syndrome) as well as to the blood coagulation pattern of the patient.

A good understanding of the pathophysiology of the cirrhotic patient is very important for best decision making. Adequate perioperative management is extremely important for a successful liver transplantation with a good outcome.
