Fig. 3.

Spectrum of postoperative coagulopathy and bleeding in liver transplantation. CVP, central venous pressure; HAT, hepatic artery thrombosis. Fig. 3 represents the spectrum of postoperative bleeding and coagulopathy liver transplant recipients can manifest. Patients with massive bleeding often coincide with graft dysfunction. This requires empiric transfusions and coagulation assessment serves as a retrospective marker for progress in correcting coagulopathy. As bleeding slows and coagulation assessment results return, the more hemostatic blood products (fibrinogen and platelets) can be given first as indicated by VET. Some liver transplant recipients begin to demonstrate evidence of fluid overload during this phase causing increased CVP that can be exacerbated by declining renal function which can exacerbate graft dysfunction. A more judicious approach to goal-based resuscitation can be utilized at this time with scheduled coagulation assessment until clinical bleeding has resolved. Ultimately these transition into hemodynamic stability and coagulation assessment can be spaced out to several hours and treatment can be based on evidence of bleeding. On the opposite end of the spectrum are patients who come from the operating room with minimal bleeding. These patients can be treated with limited coagulation assessment and transfusions limited to evidence of bleeding. In this patient population, there also may be individuals who are increased risk of thrombotic complications. They can be managed by scheduling coagulation assessment with a restrictive transfusion strategy with consideration of heparin infusion orantiplatelet in the postoperative setting. Most liver transplant patients come out of the operating room between these two extremes and their coagulation assessment and transfusion triggers are guided on where they fall on the spectrum of active bleeding control with the consideration of thrombosis. The most challenging patients to manage are those who emerge with massive bleeding and graft dysfunction which leads to fluid overload with renal impairment and subsequent increased risk for postoperative thrombotic complications. The shifting of transfusion strategies in this population requires a careful vigilant team approach as mismanagement can lead to massive bleeding or thrombosis.