Abstract
Background
Optimal haemostasis management in orthotropic liver transplant (OLT) could reduce blood loss and transfusion volume, improve patient outcomes and reduce cost.
Methods
We performed a study including 336 OLTs to evaluate the clinical and cost effectiveness of a new point-of-care (POC)-based haemostatic management approach in OLT patients.
Results
In terms of health benefit we found that the new approach showed a significant reduction in transfusion requirements (red blood cell transfusion units were reduced from 5.3±4.6 to 2.8±2.9 [p<0.001], free frozen plasma from 3.1±3.3 to 0.4±1.0 [p<0.001] and platelets from 2.9±3.9 to 0.4±0.9 [p<0.001], transfusion avoidance, 9.7% vs. 29.1% [p<0.001] and massive transfusion, 14.5% vs. 3.8% [p=0.001]); we also found a significant improvement in patient outcomes, such, reoperation for bleeding or acute-kidney-failure (8.3% vs. 2.4%, p=0.015; 33.6% vs. 5.4%, p<0.001), with a significant reduction in the length of the hospital total stay (40.6±13.8 days vs. 38.2±14.4 days, p=0.001). The lowest cost incurred was observed with the new approach (€73,038.80 vs. €158,912.90) with significant patient saving associated to transfusion avoidance (€1278.36), ICU-stay (€3037.26), total-stay (€3800.76) and reoperation for bleeding (€80,899.64).
Conclusions
POC haemostatic monitoring during OLT is cost effective.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organisation(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Polak WG, Soyama A, Slooff MJ. Liver transplantation in patients with hepatocellular carcinoma. Ann Transplant 2008;13:5–15.Search in Google Scholar
2. Markiewicz-Kijewska M, Szymczak M, Ismail H, Prokurat S, Teisseyre J, Socha P, et al. Liver transplantation for fulminant Wilson’s disease in children. Ann Transplant 2008;13:28–31.Search in Google Scholar
3. Mannucci PM. Abnormal hemostasis tests and bleeding in chronic liver disease: are they related? No. J Thromb Haemost 2006;4:721–3.10.1111/j.1538-7836.2006.01886.xSearch in Google Scholar PubMed
4. Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Reduction of blood product transfusions during liver transplantation. Can J Anaesth 2005;52:545–6.10.1007/BF03016538Search in Google Scholar PubMed
5. Porte RJ, Hendriks HG, Slooff MJ. Blood conservation in liver transplantation: The role of aprotinin. J Cardiothorac Vasc Anesth 2004;18:31S–7.10.1053/j.jvca.2004.05.004Search in Google Scholar PubMed
6. Ramos E, Dalmau A, Sabate A, Lama C, Llado L, Figueras J, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl 2003;9:1320–7.10.1016/jlts.2003.50204Search in Google Scholar PubMed
7. Ozier Y, Pessione F, Samain E, Courtois F; French Study Group on Blood Transfusion in Liver Transplantation. Institutional variability in transfusion practice for liver transplantation. Anesth Analg 2003;97:671–9.10.1213/01.ANE.0000073354.38695.7CSearch in Google Scholar PubMed
8. Massicotte L, Sassine MP, Lenis S, Seal RF, Roy A. Survival rate changes with transfusion of blood products during liver transplantation. Can J Anaesth 2005;52:148–55.10.1007/BF03027720Search in Google Scholar PubMed
9. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, Slooff MJ, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg 2008;106:32–44.10.1213/01.ane.0000289638.26666.edSearch in Google Scholar PubMed
10. Coakley M, Reddy K, Mackie I, Mallett S. Transfusion triggers in orthotopic liver transplantation: a comparison of the thromboelastometry analyzer, the thromboelastogram, and conventional coagulation tests. J Cardiothorac Vasc Anesth 2006;20:548–53.10.1053/j.jvca.2006.01.016Search in Google Scholar PubMed
11. Roullet S, Pillot J, Freyburger G, Biais M, Quinart A, Rault A, et al. Rotation thromboelastometry detects thrombocytopenia and hypofibrinogenaemia during orthotopic liver transplantation. Br J Anaesth 2010;104:422–8.10.1093/bja/aeq022Search in Google Scholar PubMed
12. Massicotte L, Beaulieu D, Thibeault L, Roy JD, Marleau D, Lapointe R, et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008;85:956–62.10.1097/TP.0b013e318168fcd4Search in Google Scholar PubMed
13. Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood 2010;116:878–85.10.1182/blood-2010-02-261891Search in Google Scholar PubMed
14. Leon-Justel A, Noval-Padillo JA, Alvarez-Rios AI, Mellado P, Gomez-Bravo MA, Álamo JM, et al. Point-of-care haemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome. Clin Chim Acta 2015;446:277–83.10.1016/j.cca.2015.04.022Search in Google Scholar PubMed
15. Davies L, Brown TJ, Haynes S, Payne K, Elliott RA, McCollum C. Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model. Health Technol Assess 2006;10:iii–iv, ix–x, 1–210.10.3310/hta10440Search in Google Scholar PubMed
16. Craig J, Aguiar-Ibanez R, Bhattacharya S, Downie S, Duffy S, Kohli H, et al. The clinical and cost effectiveness of thromboelastography/thromboelastometry. HTA Programme: Health Technology Assessment Report 11 ~ June 2008. 2008.Search in Google Scholar
17. Claxton K, Sculpher M, McCabe C, Briggs A, Akehurst R, Buxton M, et al. Probabilistic sensitivity analysis for NICE technology assessment: not an optional extra. Health Econ 2005;14:339–47.10.1002/hec.985Search in Google Scholar PubMed
18. Wegner J, Popovsky MA. Clinical utility of thromboelastography: one size does not fit all. Semin Thromb Hemost 2010;36: 699–706.10.1055/s-0030-1265286Search in Google Scholar PubMed
19. Feltracco P, Brezzi M, Barbieri S, Galligioni H, Milevoj M, Carollo C, et al. Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation. World J Hepatol 2013;5:1–15.10.4254/wjh.v5.i1.1Search in Google Scholar PubMed PubMed Central
20. Wang SC, Shieh JF, Chang KY, Chu YC, Liu CS, Loong CC, et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transpl Proc 2010;42:2590–3.10.1016/j.transproceed.2010.05.144Search in Google Scholar PubMed
21. Dalmau A, Sabaté A, Koo M, Bartolomé C, Rafecas A, Figueras J, et al. The prophylactic use of tranexamic acid and aprotinin in orthotopic liver transplantation: a comparative study. Liver Transpl 2004;10:279–84.10.1002/lt.20075Search in Google Scholar PubMed
22. Frasco PE, Poterack KA, Hentz JG, Mulligan DC. A comparison of transfusion requirements between living donation and cadaveric donation liver transplantation: relationship to model of end-stage liver disease score and baseline coagulation status. Anesth Analg 2005;101:30–37.10.1213/01.ANE.0000155288.57914.0DSearch in Google Scholar PubMed
23. Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg 2004;98:1245–51.10.1213/01.ANE.0000111184.21278.07Search in Google Scholar PubMed
24. Leon-Justel A, Noval-Padillo JA, Polonio F, Gomez-Cia T, Hinojosa R, Porras M, et al. Mobile Laboratory Unit: a disruptor solution for hemostasis management during major surgery. Usage in the context of face transplantation. Clin Chem Lab Med 2012;50:1621–4.10.1515/cclm-2011-0764Search in Google Scholar
25. Hendriks HG, van der Meer J, de Wolf JT, Peeters PM, Porte RJ, de Jong K, et al. Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation. Transpl Int 2005;17:673–9.10.1007/s00147-004-0793-5Search in Google Scholar
26. Ojo AO, Held PJ, Port FK, Wolfe RA, Leichtman AB, Young EW, et al. Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med 2003;349:931–40.10.1056/NEJMoa021744Search in Google Scholar
27. Adam R, Cailliez V, Majno P, Karam V, McMaster P, Caine RY, et al. Normalised intrinsic mortality risk in liver transplantation: European Liver Transplant Registry study. Lancet 2000;356:621–7.10.1016/S0140-6736(00)02603-9Search in Google Scholar
28. Goh A. An analysis of liver transplant survival rates from the UNOS registry. Clin Transpl 2008:19–34.Search in Google Scholar
29. Afshari A, Wikkelso A, Brok J, Moller AM, Wetterslev J. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 2011:CD007871.10.1002/14651858.CD007871.pub2Search in Google Scholar PubMed
30. Bilbao I, Armadans L, Lazaro JL, Hidalgo E, Castells L, Margarit C. Predictive factors for early mortality following liver transplantation. Clin Transplant 2003;17:401–11.10.1034/j.1399-0012.2003.00068.xSearch in Google Scholar PubMed
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