Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1016/j.bjane.2018.01.016
Brazilian Journal of Anesthesiology
Clinical Information

Monitoring of coagulation by intraoperative thromboelastometry of liver transplantation in a patient using warfarin - case report

Monitoração da coagulação pela tromboelastometria no intraoperatório de transplante hepático em um paciente usando varfarina - relato de caso

José Carlos Rodrigues Nascimento; David Silveira Marinho; Rodrigo Dornfeld Escalante; Bodiyabaduge Emmanuel M. Daya Pereira Junior; Cristiane Gurgel Lopes; Rogean Rodrigues Nunes

http://dx.doi.org/10.1016/j.bjane.2018.01.016 Braz J Anesthesiol, vol.68, n6, p.645-649, 2018
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Abstract

Abstract Introduction: Advanced hepatic disease may - in addition to the widely recognized hemorrhagic complications - occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM®). Case report: A 56 year-old male patient diagnosed with alcohol cirrhosis using warfarin (2.5 mg.day−1) for partial portal vein thrombosis with the International Normalized Ratio (INR) of 2.14. At the beginning of surgery, the ROTEM® parameters were all normal. In the anhepatic phase, EXTEM and INTEM remained normal, but FIBTEM showed reduction of amplitude after 10 min and maximum clot firmness. Finally, in the neohepatic phase, there was a slight alteration in the hypocoagulability of most of the parameters of the EXTEM, INTEM and FIBTEM, besides a notable correction of the Coagulation Time (CT) in HEPTEM compared to the CT of the INTEM. Therefore, the patient did not receive any transfusion of blood products during surgery and in the postoperative period, being discharged on the 8th postoperative day. Discussion: Coagulation deficit resulting from cirrhosis distorts INR as a parameter of anticoagulation adequacy and as a determinant of the need for blood transfusion. Thus, thromboelastometry can provide important information for patient management.

Keywords

Thromboelastometry, Coagulation, Warfarin, Liver transplantation

Resumo

Resumo Introdução: A doença hepática avançada pode, além das complicações hemorrágicas amplamente reconhecidas, ocorrer com eventos trombóticos. Descrevemos o caso de um paciente cirrótico em uso de varfarina, cujo manejo da coagulação durante o transplante de fígado foi guiado por tromboelastometria (ROTEM®). Relato de caso: Paciente do sexo masculino, 56 anos, diagnosticado com cirrose alcoólica, recebendo varfarina (2,5 mg.dia−1) para trombose parcial da veia porta, com razão normalizada internacional (INR) de 2,14. No início da cirurgia, os parâmetros ROTEM® estavam todos normais. Na fase não hepática, EXTEM e INTEM permaneceram normais, mas FIBTEM mostrou redução da amplitude após 10 min e firmeza máxima do coágulo. Por fim, na fase neo-hepática houve uma ligeira alteração da hipocoagulabilidade na maioria dos parâmetros de EXTEM, INTEM e FIBTEM, além de uma correção notável do tempo de coagulação (CT) de HEPTEM em comparação com o CT de INTEM. Portanto, o paciente não recebeu transfusão de hemoderivados durante a cirurgia e no período pós-operatório, obteve alta no oitavo dia de pós-operatório. Discussão: O déficit de coagulação resultante da cirrose distorce o INR como um parâmetro da adequação da anticoagulação e como um determinante da necessidade de transfusão de sangue. Portanto, a tromboelastometria pode fornecer informações importantes para o manejo do paciente.

Palavras-chave

Tromboelastometria, Coagulação, Varfarina, Transplante hepático

References

Tripodi A, Primignani M, Chantarangkul V. An imbalance of pro- vs anti coagulation factors in plasma from patients with cirrhosis. Gastroenterology. 2009;137:2105-11.

Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood. 2010;116:878-85.

Northup PG. Hypercoagulation in liver disease. Clin Liver Dis. 2009;13:109-16.

Wanless IR, Wong F, Blendis LM. Hepatic and portal vein thrombosis in cirrhosis: possible role in development of parenchymal extinction and portal hypertension. Hepatology. 1995;21:1238-47.

Dargaud Y, Hoffman M, Lefrapper L. Bleeding risk in warfarinized patients with a therapeutic international normalized ratio: the effect of low factor IX levels. J Thromb Haemost. 2013;11:1043-52.

Leissinger CA, Blatt PM, Hoots WK. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol. 2008;83:137-43.

Whiting D, Dinardo JA. TEG and ROTEM: technology and clinical applications. Am J Hematol. 2014;89:228-32.

Schmidt DE, Holmström M, Majeed A. Detection of elevated INR by thromboelastometry and thromboelastography in warfarin treated patients and healthy controls. Thromb Res. 2015;135:1007-11.

Durila M, Schützner J, Vymazal T. The role of rotational thromboelastometry (ROTEM) in the perioperative period in a warfarinized patient (case report). Rozhl Chir. 2016;95:329-32.

Hepner DL, Concepcion M, Bhavani-Shankar K. Coagulation status using thromboelastography in patients receiving warfarin prophylaxis and epidural analgesia. J Clin Anesth. 2002;14:405-10.

Haas T, Spielmann N, Mauch J. Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth. 2012;108:36-41.

Blasi A, Muñoz G, De Soto I. Reliability of thromboelastometry for detecting the safe coagulation threshold in patients taking acenocoumarol after elective heart valve replacement. Thromb Res. 2015;136:669-72.

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