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IMPACT ON TRANSFUSION REQUIREMENTS, PATIENT OUTCOMES, AND HEALTH CARE COSTS

  • Hemostasis in cirrhosis is rebalanced on a lower level that can rapidly devolve to bleeding and thrombosis (Fig. 57-1).1–4

  • The hemostatic changes are better reflected by viscoelastic testing rather than standard coagulation laboratory tests (SCLTs) such as PT/INR (international normalized ratio), aPTT, and platelet count.5–9

  • Clear evidence for the clinical utility of TEG/ROTEM protocols exist, as they prevent both over-transfusion and undertransfusion.10–20

  • The traditional TEG works with a free-pending pin in a rotating cuvette. The clotting process is detected via a torsion wire. Due to the free suspension of the pin, the TEG is extremely sensitive to vibrations and mechanical shocks. This flaw is overcome in the ROTEM system by using a rotating pin fixed on a steel axis, which is stabilized by a unique ball bearing and a precise optical detection method. Clinically relevant parameters of ROTEM and TEG are shown in Fig. 57-2. Characteristic ROTEM traces in various coagulation conditions are shown in Fig. 57-3. Various activators used in different ROTEM assays and their implications are shown in Table 57-1.

FIGURE 57-1

Hemostasis rebalance in cirrhosis. α2-AP, α2-Antiplasmin; AT, antithrombin; LPS, lipopolysaccharides; PAI-1, plasminogen activator inhibitor-1; RES, reticuloendothelial system; tPA, tissue plasminogen activator; vWF, von Willebrand factor. <FGSO>. (Reproduced with permission from of Klaus Görlinger, Essen, Germany.)

FIGURE 57-2

ROTEM (“temogram”) and TEG trace displaying the clinically most important parameters and their informative value. FDPs, fibrin(ogen) split products. (Reproduced with permission from of Klaus Görlinger, Essen, Germany.)

FIGURE 57-3

A-J. Characteristic thromboelastometry traces. The diagnostic performance is increased by test combinations, e.g., EXTEM and FIBTEM, EXTEM and APTEM, or INTEM and HEPTEM. 4F-PCC, Four factor prothrombin complex concentrate; A5, amplitude of clot firmness 5 min after CT; CFT, clot formation time; CPB, cardiopulmonary bypass, CT, coagulation time; LI60, lysis index 60 min after CT; MCF, maximum clot firmness; ML, maximum lysis during runtime; OLT, orthotopic liver transplantation; TXA, tranexamic acid (or other antifibrinolytic drug). (Reproduced with permission from of Klaus Görlinger, Essen, Germany.)

a figure shows five characteristic thromboelastometry traces, using combination of extem and fibtem, or extem and aptem. the figure shows five characteristic thromboelastometry traces, using combination of extem and fibtem, or extem and aptem. the tracing at the top shows normal clot with both extem and fibtem: ctex 43–82 s, a5ex 33–52 mm, mcfex 52–70 mm, mlex or mlfib < 15%, li60ex or li60fib > 85%, a5fib 5–20 mm and mcffib 7–24 mm. below the normal clot figure is hyperfibrinolysis is shown using both extem and aptem: mlex ≥15% or mlfib ≥ 10% within 60 min (li60 ≤ 85%); aptem confirms txa effect; note: fibtem is most sensitive and specific to hyperfibrinolysis! below the hyperfibrinolysis figure fibrin polymerization disorder (e.g., low fibrinogen or low fxiii or colloid infusion) is shown with both extem and fibtem: a5ex < 35 mm and a5fib < 9 mm. next, thrombocytopenia or severe platelet dysfunction (thrombin pathway or gpiibiiia-r) is shown with both extem and fibtem: a5ex < 35 mm and a5fib ≥ 9 mm. at the bottom, ... id=

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