Anesth Analg 2001;93:802
© 2001 International Anesthesia Research Society
LETTERS TO THE EDITOR
Heparin Effect After Hepatic Artery Anastomosis During Liver Transplantation
Evan G. Pivalizza, MBChB, FFASA,
Manfred K. Raber, MD,
Claire F. Ozaki, MD,
Jacqueline A. Lappin, MD, and
R. Patrick Wood, MD
Departments of Anesthesiology and Surgery, University of Texas Health Science Center-Houston, Houston, TX
To The Editor:
Use of the heparinase-modified Thrombelastograph® (TEG®; Haemoscope, Skokie, IL) has facilitated the diagnosis and management of heparin activity after portal vein reperfusion of the hepatic graft during orthotopic liver transplantation (1–3). We present a case of heparin effect after hepatic artery (HA) reperfusion without prior effect after portal vein reperfusion.
A 60-yr-old woman underwent orthotopic liver transplantation for hepatitis C-induced cirrhosis. After initial reperfusion via the portal vein, the TEG® values were unchanged. However, after HA anastomosis, generalized oozing was evident, and the TEG® readings confirmed delayed onset of fibrin formation (prolonged R and K times, decreased angle), which was corrected with in vitro heparinase (Fig. 1). Protamine was administered, the bleeding abated, and the remainder of the case was uneventful.
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Figure 1. Native (A) and heparinase-modified (B) Thrombelastograph® (Haemoscope, Skokie, IL) tracings. Trace A: r = 7.5 mm, K = 4 mm, Angle = 68 deg, Maximum amplitude (MA) = 56 mm; Trace B: r = 36, K = 18, Angle = 46 deg, MA = 48 mm.
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There was no deviation from standard donor heparinization (300 U/kg), organ storage solution (University of Wisconsin), flushing of the graft before portal vein anastomosis (500 mL cold albumin), concentration of heparinized saline during anastomosis (10 U/mL), and no heparin was used in the arterial or central venous catheter flush solution.
The identification of a heparin effect with the heparinase-Thrombelastograph® is well documented after initial revascularization of liver grafts (1–3). There has been no prior evidence of such an effect after HA anastomosis, presumably because of clearance of heparin/heparin-like substances and passive back bleeding before anastomosis. This case suggests that physicians should be aware of the possibility of a delayed heparin effect after HA anastomosis, which may be attributable to either the release of donor-administered heparin or endogenous production by the arterial endothelium.
References
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Kettner SC, Gonano C, Seebach F, et al. Endogenous heparin-like substances significantly impair coagulation in patients undergoing orthotopic liver transplantation. Anesth Analg 1998; 86: 691–5.[Abstract]
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Pivalizza EG, Abramson DC, King FS Jr. Thrombelastography with heparinase in orthotopic liver transplantation. J Cardiothorac Vasc Anesth 1998; 12: 305–8.[Web of Science][Medline]
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Harding SA, Mallett SV, Peachey TD, Cox DJ. Use of heparinase modified thrombelastography in liver transplantation. Br J Anaesth 1997; 78: 175–9.[Abstract/Free Full Text]
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