© 2013 John Wiley & Sons A/S. Clin Transplant 2013 DOI: 10.1111/ctr.12067 Rotational thromboelastometry and standard coagulation tests for live liver donors Mohammed M, Fayed N, Hassanen A, Ahmed F, Mourad W, El Maged Mohammeda, Nirmeen Sheikh M, Abofetouh F, Yassen K, Khalil M, Marwan I, Tanaka K. Fayedb, Ashraf Hassanenb, Fatma Rotational thromboelastometry and standard coagulation tests for Ahmedb, Wessam Mouradc, Maha live liver donors. El Sheikhb, Fawzia Abofetouha, Khaled Yassenb, Magdy Khalilb, Abstract: Purpose: To study coagulation of live liver donors with Ibrahim Marwand and Koichio standard coagulation tests (SCT) and rotational thromboelastometry Tanakad (ROTEM) and investigate their relationship. a Methods: A descriptive prospective study involving 50 right hepatotomy Department of Anaesthesia, Cairo University, b donors with epidural catheters. ROTEM (EXTEM, INTEM, and Cairo, Department of Anaesthesia, Liver FIBTEM represent extrinsic and intrinsic pathways of coagulation and Institute, Menoufiya University, Shebeen El c fibrinogen activity, respectively) was measured perioperatively and on Kom, Department of Community Medicine days 1, 3, 5, 10, and 30. SCTs include prothrombin time (PT), and Statistics, Liver Institute, Menoufiya d international normalized ratio (INR) of PT, activated partial University and Department of Surgery, Liver thromboplastin time (aPPT), fibrinogen, and platelets. Institute, Menoufiya University, Shebeen El Results: PT and INR reflect hypocoagulability reaching maximum on Kom, Egypt day one (16.9 Æ 2.5 s, 1.4 Æ 0.2, p < 0.05 compared with baseline). ROTEM was in normal ranges till day 30 with no hypercoagulability. Key words: coagulation – live donors – liver Fibrinogen showed no correlation with maximum clot firmness (MCF) of resection – rotational thromboelastometry FIBTEM (r = 0.35, p > 0.05). CFT of EXTEM was not in significant correlation with PT and INR (r = 0.16, 0.19, p > 0.05), respectively. Corresponding author: Khaled Yassen, MD, Significant correlation between platelets and both MCF (EXTEM; FFARCSI, Department of Anesthesia, Liver r = 0.59, p = 0.004) and MCF (INTEM; r = 0.48, p = 0.027). Institute, Menoufiya University, Shebeen Conclusion: ROTEM disagreed with SCTs and did not show the ElKom, Egypt. temporary hypocoagulability suggested by SCTs. Both ROTEM and Tel.: +20 106 3080170; fax: +20 482 234586; SCTs showed no signs of hypercoagulability. Future studies involving e-mail: [email protected] ROTEM could help develop new guidelines for coagulation monitoring. Conflict of interest: The authors have no conflict of interests to disclose. Accepted for publication 7 November 2012 Living donor liver transplantation is currently an concern when an epidural catheter is inserted for acceptable alternative offered to patients with end- pain control. Postoperative coagulopathy is stage liver disease, and it has been successfully currently diagnosed by abnormalities in standard performed in many centers around the world. coagulation tests (SCTs) such as the prothrombin However, despite improved techniques and results, time (PT), partial thromboplastin time (PTT), and donor safety still remains a major concern (1). low platelet count (3). The rotational thromboelas- Removal of a considerable hepatic mass could tometry (ROTEM) studies can evaluate the process reduce the hepatic synthesis of clotting factors of clot initiation, formation, and stability with resulting in a hypocoagulable state. Alternatively, whole blood or plasma, based on the viscoelastic a hypercoagulable profile can also result from properties of blood (4). diminished hepatic synthesis of anticoagulants (2). This study aims to investigate the coagulation Both hypercoagulability and hypocoagulability profile during and after right hepatotomy for the could impose a risk for the volunteers during and purpose of adult living-related liver transplanta- after the process of donation with a particular tion by the use of SCTs and ROTEM. 1 Mohammed et al. the epidural catheter in 5 mL increments as Patients and methods required. Maximum dose according to weight was Approval for this descriptive cross-sectional pro- calculated to avoid over dosage. spective study (2007–2011) was provided by the The surgical technique was standardized; an Research Ethic Board of the Liver Institute, Meno- ultrasonic dissector was used to divide the liver ufiya University, Shebeen El Kom city, Egypt parenchyma. No Pringle maneuver was performed (Chairperson Prof. Magdy Kamal) on 5 November at any stage. The Pringle maneuver is a surgical 2007 (Ethic committee No. MD12). Informed writ- technique used in abdominal operations, in which ten consent was obtained from each donor. Fifty a vascular clamp is applied to the hepatoduodenal consecutive adult living liver donors undergoing ligament interrupting the flow of blood through right liver resection for living-related liver trans- the hepatic artery and the portal vein to control plantation at the Liver Institute were included in blood flow to the liver or bleeding. It was devel- this study. Donors aborted prior to schedule for oped by James Hogarth Pringle (5). The Pringle surgery were excluded from the study and replaced maneuver is often used during liver surgery to min- by other volunteers. Reasons for exclusion are imize blood loss; however, it can directly lead to mentioned in the Results section. reperfusion phenomenon in the liver. Eligibility criteria for donors included in the In all donors, a right hepatectomy along the study include age between 20 and 45 yr and rela- Cantlie line was performed, including segments tionship within the third degree of consanguinity 5–8, without involving the middle hepatic vein. with the recipient as well as ABO blood group Sodium heparin (15 IU/kg) was administered compatibility. Negative serology for hepatic intravenously before vascular clamping, following viruses is a must. Normal laboratory results for the hypothesis that this could prevent intrahepatic electrolytes, hepatic and renal functions are thrombosis. required. Routine coagulation studies in addition All living donors were extubated while still in to protein C, protein S, antithrombin III, and fac- the operating room. Postoperative analgesia was tor V leiden mutation were performed. A graft provided by patient-controlled epidural analgesia weight with a ratio of more than 0.8% of the reci- (PCEA), using 0.125% bupivacaine plus pient’s body weight (GRWR > 0.8) is necessary 2 lg fentanyl/mL. The PCEA pump was pro- for a successful living donor liver transplantation grammed for a basal infusion rate of 6 mL/h and (LDLT). A percutaneous ultrasound-guided liver 3 mL bolus every 15 min when needed. The aim biopsy was routinely performed to assess the status was to achieve a visual analog pain score of 3 or of the liver and the degree of steatosis. less. Low-molecular-weight heparin (LMWH; Preoperative investigations included full blood 40 mg of enoxaparin) was given subcutaneously cell count, thyroid function tests, pregnancy tests, once daily for all donors from the second postop- full virological tests and bacteriological cultures, erative day until hospital discharge. Any blood chest radiograph, electrocardiogram plus Doppler products given were reported. The administration cardiac ultrasound, respiratory spirometry, liver of non-steroidal anti-inflammatory drugs was Doppler examination, magnetic resonance imaging avoided perioperatively. The epidural catheter (MRI), angiography, and cholangiography and a was only removed when the international normal- volumetric study of the whole liver and the right ized ratio (INR) was <1.4 and the platelet count lobe. The volume and weight of the resected right was >100 9 103 cells/mm3 and not before 12 h lobe was calculated. from the last dose of LMWH. The following On admission to the operating room and after dose of heparin was given 12 h after epidural standard basic monitoring, a thoracic epidural catheter removal. catheter was placed between T6 and T11 preopera- The ROTEM analysis was performed for each tively after patient consent. General anesthesia was patient: before the skin incision baseline (Pre-Op), induced with propofol (2 mg/kg), rocuronium on postoperative day one (D1, 24 h after surgery), (0.6 mg/kg), and fentanyl (2 lg/kg), followed by and on postoperative days 3, 5, 10, and 30 (D3, an endotracheal intubation. General anesthesia D5, D10, and D30). The SCTs (PT, PTT, INR, was maintained with a mixture of air/oxygen and platelets) were also measured at the same time. The sevoflurane with low flow at 2 L/min. An arterial sampling was performed before the next LMWH line was routinely inserted into the left radial dose in all donors. For ROTEM analysis, 4 mL of artery, and a central venous line was inserted blood was drawn, and it was immediately mixed into the right internal jugular vein with ultra- with 0.5 mL of a 3.2% citrate sodium solution sound guidance. During surgery, bupivacaine followed by gentle mixing, and the blood samples 0.125% + 2 lg/mL fentanyl was injected through were analyzed at 37°C. 2 Coagulation changes with live liver donors The following ROTEM tests (Pentapharm, was defined when at least two or more parameters Munich, Germany) were performed for each were altered. sample: intrinsically activated thromboelastome- try (INTEM), which evaluates the formerly Statistical analysis known coagulation cascade intrinsic pathway; extrinsically activated thromboelastometry All data were tested with Kolmogorov–Smirnov (EXTEM), evaluates the