Técnicas y medidas tendientes a disminuir el sangrado y el consumo de hemocomponentes en trasplante hepático
Evaluación de los primeros dos años de la Unidad Bi-Institucional de Trasplante Hepático en la especialidad Medicina Transfusional y Hemoterapia
Palabras clave:
TRASPLANTE DE HÍGADO, TRANSFUSIÓN SANGUÍNEA, TRANSFUSIÓN DE COMPONENTES SANGUÍNEOS, HEMORRAGIAResumen
Introducción: el trasplante hepático (TH) es el único tratamiento definitivo para la enfermedad hepática terminal crónica y patologías que no cuentan con otra alternativa terapéutica. El sangrado y el consumo de hemocomponentes se ha vinculado al descenso de la sobrevida del injerto y del paciente.
Objetivo: evaluar los resultados en el consumo de hemocomponentes con la utilización de medidas y técnicas tendientes a minimizar el sangrado. Estimar la sobrevida.
Material y método: se realiza un estudio descriptivo, observacional, retrospectivo de los primeros 31 pacientes sometidos a TH. Para la búsqueda de asociación entre variables de tipo cualitativo se utilizó test de chi cuadrado para un nivel de significación α= 0,05, para el análisis de sobrevida fue utilizado Kaplan-Meyer. Resultados: se diseñó un score para analizar el consumo de hemocomponentes; en cinco pacientes (16,1%) no se transfundieron unidades de sangre desplasmatizada (u SD) y en 58,1% se consumieron de 1 a 4 u SD, con un promedio de 3,7 ± 0,6. Un solo paciente (3,2%) se trasplantó sin transfusión de hemocomponentes. A los seis meses la sobrevida corresponde a 81,3%, con un total de cinco eventos, permaneciendo vivos al final del estudio 26 pacientes. Conclusiones: las medidas para disminuir el sangrado y los requerimientos transfusionales fueron efectivos. Los resultados fueron aceptables, cercanos a los publicados a nivel internacional.
Citas
(1) Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5(4):165-82.
(2) Pandey CK, Singh A, Kajal K, Dhankhar M, Tandon M, Pandey VK, et al. Intraoperative blood loss in orthotopic liver transplantation: the predictive factors. World J Gastrointest Surg 2015; 7(6):86-93.
(3) Starzl TE, Marichioro TL, von Kaulla KN, Herman G. Homotransplantation of the liver in humans. Surg Gynecol Obstet 1963; 117:659-76.
(4) 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(12):1320-7.
(5) 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(2):148-55.
(6) 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(11):673-9.
(7) 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(1):32-44.
(8) Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol 2014; 20(20):6146-58.
(9) 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):1-15.
(10) Butler P, Israel L, Nusbacher J, Jenkins DE Jr, Starzl TE. Blood transfusión in liver transplantation. Transfusion 1985; 25(2):120-3.
(11) Massicotte L, Capitanio U, Beaulieu D, Roy JD, Roy A, Karakiewicz PI. Independent validation of a model predicting the need for packed red blood cell transfusion at liver transplantation. Transplantation 2009; 88(3):386-91.
(12) Marín-Gómez LM, Tinoco-González J, Alamo-Martínez JM, Suárez-Artacho G, Bernal-Bellido C, Serrano-Díaz-Canedo J, et al. Impact of the learning curve on the outcome of domino liver transplantation. Transplant Proc 2014; 46(9):3092-4.
(13) 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(3):671-9.
(14) Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg 2004; 98(5):1245-51.
(15) 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(5):545-6.
(16) Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105(4):401-16.
(17) Fayed N, Mourad W, Yassen K, Görlinger K. Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation. Transfus Med Hemother 2015; 42(2):99-108.
(18) Rodríguez A. Coagulopatía y manejo del sangrado en trasplante hepático. En: Calvo SM. Principios de hemoterapia en el paciente grave. Montevideo: Cuadrado, 2014:353-88.
(19) Grumberg G, Rando K, Zunini G. Experiencia en la Unidad Bi-Institucional de Trasplante Hepático en Uruguay. Anest Analg Reanim 2010; 23(1):18- 26.
(20) Mangus RS, Kinsella SB, Nobari MM, Fridell JA, Vianna RM, Ward ES, et al. Predictors of blood product use in orthotopic liver transplantation using the piggyback hepatectomy technique. Transplant Proc 2007; 39(10):3207-13.
(21) Miyamoto S, Polak WG, Geuken E, Peeters PM, de Jong KP, Porte RJ, et al. Liver transplantation with preservation of the inferior vena cava: a comparison of conventional and piggyback techniques in adults. Clin Transplant 2004; 18(6):686-93.
(22) Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl 2006; 12(1):117-23.
(23) Massicotte L, Beaulieu D, Thibeault L. Con: low central venous pressure during liver transplantation. J Cardiothorac Vasc Anesth 2008; 22(2):315-7.
(24) Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJ, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant 2007; 7(1):185-94.
(25) Dalmau A, Sabaté A, Acosta F, Garcia-Huete L, Koo M, Sansano T, et al. Tranexamic acid reduces red cell transfusión better than epsilon-aminocaproic acid or placebo in liver transplantation. Anesth Analg 2000; 91(1):29-34.
(26) Rodríguez A, Rodríguez I, Decaro J. Manual de procedimientos operativos. Programa de trasplante hepático. Montevideo: Cátedra y Dpto. de Medicina Transfusional de la Facultad de Medicina de UDELAR, 2009.
(27) Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30(6):270- 382.
(28) American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 2015; 122(2):241-75.
(29) Rimola A. Trasplante hepático. Med Clin (Barc) 1999; 112(7): 270.
(30) Cuevas-Mons V. Trasplante hepático. Barcelona: Sandoz-Pharma, 1993.
(31) España. Ministerio de Sanidad y Consumo. Agencia de evaluación de tecnologías sanitarias. Indicaciones y contraindicaciones del trasplante y retrasplante hepático. Madrid: AETS - Instituto San Carlos III, 1995.
(32) Görlinger K. Coagulation management during liver transplantation. Hamostaseologie 2006; 26(3 Suppl 1):S64-76.
(33) Görlinger K, Fries D, Dirkmann D, Weber CF, Hanke AA, Schöchl H. Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy. Transfus Med Hemother 2012; 39(2):104-113.
(34) 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.
(35) Noval-Padillo JA, León-Justel A, Mellado-Miras P, Porras-Lopez F, Villegas-Duque D, Gomez-Bravo MA, et al. Introduction of fibrinogen in the treatment of hemostatic disorders during orthotopic liver transplantation: implications in the use of allogenic blood. Transplant Proc 2010; 42(8):2973-4.
(36) Calvo SM. Transfusión masiva. En: Calvo SM. Principios de hemoterapia en el paciente grave. Montevideo: Cuadrado, 2014:433-86.
(37) Uruguay. Universidad de la República. Facultad de Medicina. Cátedra de Hemoterapia y Medicina Transfusional. Protocolo de transfusión autóloga. Montevideo: Facultad de Medicina, 2009
(38) Morais Bruno Salome de, Sanches Marcelo Dias, Lima Agnaldo Soares, Ribeiro Daniel Dias, Ferrari Teresa Crisitna de Abreu, Duarte Mavina Maria de Freitas, et al. Asociación entre el uso de hemocomponentes y la mortalidad en cinco Años después de transplante hepático. Rev Bras Anestesiol 2011; 61(3):289-92.
(39) Boin IF, Leonardi MI, Luzo AC, Cardoso AR, Caruy CA, Leonardi LS. Intraoperative massive transfusion decreases survival after liver transplantation. Transplant Proc 2008; 40(3):789-91.
(40) Adam R, McMaster P, O’Grady JG, Castaing D, Klempnauer JL, Jamieson N, et al; European Liver Transplant Association. Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry. Liver Transpl 2003; 9(12):1231-43.
(2) Pandey CK, Singh A, Kajal K, Dhankhar M, Tandon M, Pandey VK, et al. Intraoperative blood loss in orthotopic liver transplantation: the predictive factors. World J Gastrointest Surg 2015; 7(6):86-93.
(3) Starzl TE, Marichioro TL, von Kaulla KN, Herman G. Homotransplantation of the liver in humans. Surg Gynecol Obstet 1963; 117:659-76.
(4) 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(12):1320-7.
(5) 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(2):148-55.
(6) 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(11):673-9.
(7) 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(1):32-44.
(8) Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol 2014; 20(20):6146-58.
(9) 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):1-15.
(10) Butler P, Israel L, Nusbacher J, Jenkins DE Jr, Starzl TE. Blood transfusión in liver transplantation. Transfusion 1985; 25(2):120-3.
(11) Massicotte L, Capitanio U, Beaulieu D, Roy JD, Roy A, Karakiewicz PI. Independent validation of a model predicting the need for packed red blood cell transfusion at liver transplantation. Transplantation 2009; 88(3):386-91.
(12) Marín-Gómez LM, Tinoco-González J, Alamo-Martínez JM, Suárez-Artacho G, Bernal-Bellido C, Serrano-Díaz-Canedo J, et al. Impact of the learning curve on the outcome of domino liver transplantation. Transplant Proc 2014; 46(9):3092-4.
(13) 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(3):671-9.
(14) Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg 2004; 98(5):1245-51.
(15) 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(5):545-6.
(16) Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105(4):401-16.
(17) Fayed N, Mourad W, Yassen K, Görlinger K. Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation. Transfus Med Hemother 2015; 42(2):99-108.
(18) Rodríguez A. Coagulopatía y manejo del sangrado en trasplante hepático. En: Calvo SM. Principios de hemoterapia en el paciente grave. Montevideo: Cuadrado, 2014:353-88.
(19) Grumberg G, Rando K, Zunini G. Experiencia en la Unidad Bi-Institucional de Trasplante Hepático en Uruguay. Anest Analg Reanim 2010; 23(1):18- 26.
(20) Mangus RS, Kinsella SB, Nobari MM, Fridell JA, Vianna RM, Ward ES, et al. Predictors of blood product use in orthotopic liver transplantation using the piggyback hepatectomy technique. Transplant Proc 2007; 39(10):3207-13.
(21) Miyamoto S, Polak WG, Geuken E, Peeters PM, de Jong KP, Porte RJ, et al. Liver transplantation with preservation of the inferior vena cava: a comparison of conventional and piggyback techniques in adults. Clin Transplant 2004; 18(6):686-93.
(22) Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl 2006; 12(1):117-23.
(23) Massicotte L, Beaulieu D, Thibeault L. Con: low central venous pressure during liver transplantation. J Cardiothorac Vasc Anesth 2008; 22(2):315-7.
(24) Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJ, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant 2007; 7(1):185-94.
(25) Dalmau A, Sabaté A, Acosta F, Garcia-Huete L, Koo M, Sansano T, et al. Tranexamic acid reduces red cell transfusión better than epsilon-aminocaproic acid or placebo in liver transplantation. Anesth Analg 2000; 91(1):29-34.
(26) Rodríguez A, Rodríguez I, Decaro J. Manual de procedimientos operativos. Programa de trasplante hepático. Montevideo: Cátedra y Dpto. de Medicina Transfusional de la Facultad de Medicina de UDELAR, 2009.
(27) Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30(6):270- 382.
(28) American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 2015; 122(2):241-75.
(29) Rimola A. Trasplante hepático. Med Clin (Barc) 1999; 112(7): 270.
(30) Cuevas-Mons V. Trasplante hepático. Barcelona: Sandoz-Pharma, 1993.
(31) España. Ministerio de Sanidad y Consumo. Agencia de evaluación de tecnologías sanitarias. Indicaciones y contraindicaciones del trasplante y retrasplante hepático. Madrid: AETS - Instituto San Carlos III, 1995.
(32) Görlinger K. Coagulation management during liver transplantation. Hamostaseologie 2006; 26(3 Suppl 1):S64-76.
(33) Görlinger K, Fries D, Dirkmann D, Weber CF, Hanke AA, Schöchl H. Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy. Transfus Med Hemother 2012; 39(2):104-113.
(34) 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.
(35) Noval-Padillo JA, León-Justel A, Mellado-Miras P, Porras-Lopez F, Villegas-Duque D, Gomez-Bravo MA, et al. Introduction of fibrinogen in the treatment of hemostatic disorders during orthotopic liver transplantation: implications in the use of allogenic blood. Transplant Proc 2010; 42(8):2973-4.
(36) Calvo SM. Transfusión masiva. En: Calvo SM. Principios de hemoterapia en el paciente grave. Montevideo: Cuadrado, 2014:433-86.
(37) Uruguay. Universidad de la República. Facultad de Medicina. Cátedra de Hemoterapia y Medicina Transfusional. Protocolo de transfusión autóloga. Montevideo: Facultad de Medicina, 2009
(38) Morais Bruno Salome de, Sanches Marcelo Dias, Lima Agnaldo Soares, Ribeiro Daniel Dias, Ferrari Teresa Crisitna de Abreu, Duarte Mavina Maria de Freitas, et al. Asociación entre el uso de hemocomponentes y la mortalidad en cinco Años después de transplante hepático. Rev Bras Anestesiol 2011; 61(3):289-92.
(39) Boin IF, Leonardi MI, Luzo AC, Cardoso AR, Caruy CA, Leonardi LS. Intraoperative massive transfusion decreases survival after liver transplantation. Transplant Proc 2008; 40(3):789-91.
(40) Adam R, McMaster P, O’Grady JG, Castaing D, Klempnauer JL, Jamieson N, et al; European Liver Transplant Association. Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry. Liver Transpl 2003; 9(12):1231-43.
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2016-03-31
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Rodríguez Cantera A, Cerviño G, Silveira A, Rodríguez Grecco I. Técnicas y medidas tendientes a disminuir el sangrado y el consumo de hemocomponentes en trasplante hepático: Evaluación de los primeros dos años de la Unidad Bi-Institucional de Trasplante Hepático en la especialidad Medicina Transfusional y Hemoterapia. Rev. Méd. Urug. [Internet]. 31 de marzo de 2016 [citado 21 de diciembre de 2024];32(1):8-18. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/181
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