Point-of-care coagulation monitoring during liver transplantation

SummaryLiver plays a key role in the normal haemostatic pathway. Liver failure leads to concomitant alterations in both pro-thrombotic and anti-thrombotic components of this pathway. The net effect on haemostasis is complex and patients with end-stage liver disease are at risk of bleeding episodes as well as thrombotic complications. Liver transplantation in such patients is associated with risk of massive haemorrhage due to pre-existing coagulopathy, surgical bleeding from increased collaterals due to portal hypertension and intraoperative hyperfibrinolysis. Reliable perioperative coagulation monitoring is critical in these patients to avoid coagulopathies, empirical blood transfusion and related adverse outcomes.Conventional coagulation tests do not provide information on the kinetics of clot-formation and the interaction of different components of the clotting cascade. In the setting of rapidly changing coagulation-dynamics during liver transplantation, the delay in obtaining these test results from the central laboratory is a limiting factor in guiding appropriate blood component transfusion. These limitations have led to increasing use of point-of-care coagulation monitoring devices during liver transplantation. These devices provide an immediate insight into the complex interactions between the coagulation factors, platelets, fibrinogen and clot dissolution from fibrinolysis. The rapid turnaround test times allow judicious correction of the coagulopathy thereby avoiding empirical blood transfusion. They also provide a rational guide for anti-fibrinolytic therapy and anti-thrombotic interventions.This review addresses the utility and limitations of different point-of-care coagulation tests during liver transplantation based on the available evidence. It aims to encourage appropriate implementation of these tests in the coagulation management of patients with liver failure and improve perioperative outcomes.