Viscoelastic testing and blood product utilization: a prospective study on associations and predictors of high transfusion needs in living donor liver transplantation

Abstract

Background: Anticipation of massive blood transfusion (MBT) can enhance patient care, operating room logistics and planning. Rotational thromboelastometry (ROTEM), evaluates whole blood hemostasis from initiation to hemolysis. This study aimed to determine the role of ROTEM in living donor liver transplantation (LDLT). Methods: This prospective study was conducted for adult patients undergoing LDLT at our center between March and August 2024. We analyzed ROTEM and conventional coagulation tests for their association with intraoperative packed red blood cell (PRBC) requirements. Results: In our analysis of 100 patients, the median PRBC requirement was three units (interquartile range [IQR], 2-5 units). A total of 21 patients were classified into the MBT group. The clotting time (CT) in extrinsic ROTEM (EXTEM) was significantly elevated (median, 92 sec; IQR, 77-115 sec) in the MBT group compared to the non-MBT group (median, 76 sec; IQR, 68-93 sec; P<0.01). Other parameters were comparable between the two groups. Binary regression analysis revealed spontaneous bacterial peritonitis (SBP; odds ratio [OR], 4.14; 95% confidence interval [CI], 1.15-14.90), preoperative hemoglobin (Hb) level (OR, 0.73; 95% CI, 0.54-0.98), and CT in EXTEM (OR, 1.02; 95% CI, 1.00-1.03) as independent predictors of MBT. The predictive score was 6.3 + 1.4 × (history of SBP) - 0.3 × (preoperative Hb) + 0.02 × (preoperative EXTEM CT), with SBP 1 if present and 0 if absent. This score predicted MBT with an area under the curve of 0.79. Conclusions: Preoperative CT on EXTEM was associated with a higher PRBC transfusion in the intraoperative period.