Anesth Analg 2006;103:1329
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000242643.50670.3e
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
Prevention of Intracardiac/Pulmonary Thrombosis During Liver Transplantation
Raymond M. Planinsic, MD,
Ibtesam A. Hilmi, MB, ChB, FRCA, and
Tetsuro Sakai, MD, PhD
Division of Hepatic Transplantation; Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania; planinsicrm{at}anes.upmc.edu
To the Editor:
We are writing our recommendations and standard of practice in response to the case report by Jackson et al. (1) describing an orthotopic liver transplantation (OLT) patient who developed massive intraoperative intracardiac/pulmonarythromboembolism during the dissection stage of the operation. After treatment with recombinant tissue plasminogen activator (rTPA), the patient survived and was discharged home. The authors are to be congratulated for saving the patient’s life from this catastrophe. However, it is our standard of practice to try to prevent this devastating complication from occurring, or at least to make an early diagnosis of thrombosis before a crisis develops.
Our standard of practice for OLT includes thromboelastography (TEG®), transesophageal echocardiography (TEE), pulmonary artery (PA) catheters to monitor central venous pressure, PA pressure, cardiac output/cardiac index, mixed venous oxygen saturation, left ventricular end diastolic volume and left ventricular ejection fraction, and avoidance of prophylactic antifibrinolytics (amicar or aprotinin) unless indicated. TEG allows the anesthesiologist to detect hypercoagulable states, which may then guide them to use low-dose IV heparin (2). We strongly recommend using PA catheters and TEE from the beginning of every OLT procedure. Both aid in diagnosing cardiac performance. Elevations in PA pressures may be an early sign of small pulmonary emboli. Continuous use of TEE allows the anesthesiologist to be especially vigilant in watching for early thrombus formation in the heart or on a PA catheter.
We do not believe prophylactic antifibrinolytics should be administered for every OLT patient, unless the patient is at high risk for fibrinolysis. In those situations, we use low-dose aprotinin (100,000 KIU/h or 10 mL/h), which we find successful in preventing or reversing fibrinolysis. If venovenous bypass (VVB) is used, we stop aprotinin infusion 30 min before VVB is instituted. In patients not at high risk for fibrinolysis, we administer doses of  -aminocaproic acid (amicar 125–250 mg single IV boluses) or aprotinin (10 mL bolus followed by 10 mL/h) as guided by TEG.
Jackson et al. (1) used large doses of amicar (5 g initial loading dose followed by 1 g/h IV) and cryoprecipitate and platelet infusions before the intracardiac/pulmonary thromboembolism, thus increasing the risk for thrombotic complications. No mention was made of what method was used to monitor coagulation intraoperatively. TEE and a PA catheter were placed after the event.
We believe TEG, TEE, and PA catheters may aid in early diagnosis of hypercoagualable states and guide the use of low-dose heparin to prevent thromboembolic events from happening (2–4). In our experience, if intracardiac/pulmonary thromboembolism occurs, it may be difficult to support the patient while the clot lyses. We have used TPA and streptokinase in the past. However, if the patient survives the initial catastrophe, it is unlikely that he or she will survive the massive bleeding that will occur as a result of this intervention. In conclusion, it is our opinion that preventing intracardiac/pulmonary thromboembolism is the best approach for patients undergoing OLT.
Footnotes
Dr. Jackson does not wish to respond.
REFERENCES
- Jackson D, Botea A, Gubenko Y, et al. Successful intraoperative use of recombinant tissue plasminogen activator during liver transplantation complicated by massive intracardiac/pulmonary thrombosis. Anesth Analg 2006;102:724–8.[Abstract/Free Full Text]
- Planinsic RM, Nicolau-Raducu R, Eghtesad B, Marcos A. Diagnosis and treatment of intracardiac thrombosis during orthotopic liver transplantation. Anesth Analg 2004;99:353–6.[Abstract/Free Full Text]
- DeWolf AM, Ramsey G, Teruya J, et al. Hypercoagulability and pulmonary thromboembolism (PE) during liver transplantation (LTX): what is the role of heparin administration? Liver Transpl Surg 2001;7:C-5.
- DeWolf AM, Ramsey G, Teruya J, et al. Hypercoagulability and pulmonary thromboembolism during liver transplantation: what is the role of heparin administration? Liver Transpl Surg 2003;9:C-40.
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