Massive Hemorrhage During Liver Transplantation
Jennifer D Dagen, MD and R. Victor Zhang, MD,
PhD
Department of Anesthesiology, University of Florida, Gainesville, Florida
Introduction: Liver transplantation is frequently associated with a
requirement for large quantities of blood transfusion. It is rare for
patients to bleed significantly without an underlying coagulopathy. Our case
report, however, demonstrates massive bleeding caused by an underlying
anatomical defect.
Case Report: A 15-year-old, 53 kg boy presented for his third liver
transplantation because of chronic rejection and hepatopulmonary syndrome.
His medical history was significant for biliary atresia unsuccessfully
treated with a Kasai procedure, liver transplantation at age 7 months,
post-transplant lymphoproliferative disorder at age 5, Hodgkin’s lymphoma at
age 8, second liver transplantation at age 10, and follicular thyroid cancer
at age 13. Preoperatively the patient was increasingly symptomatic from his
hepatopulmonary syndrome, becoming essentially homebound because of chronic
dyspnea and the need for supplemental oxygen. His preoperative laboratory
results showed hematocrit of 35 %, INR of 1.3, platelets of 299, and
fibrinogen of 298 mg/dl.
Induction of anesthesia was performed with fentanyl, thiopental, and
vecuronium. An arterial and large bore venous access were placed
uneventfully. Incision was made, but due to the patient’s severe adhesions
from prior procedures, the surgeons could not maintain a plane of dissection
and had to dissect through the liver. Substantial blood loss ensued and cell
saver was instituted. Hemodynamics were maintained by high volume fluid
resuscitation with an automated high volume fluid administration system. The
surgery continued with constant bleeding requiring fluid replacement rates
of 500 mL/min for 4-5 hours. Nonetheless, thrombelastography was normal and
bleeding appeared to be surgical in nature. The donor liver was not perfused
well and lactic acid values increased to greater than 13.5 mmol.L. Six hours
into the case the patient continued to bleed profusely and hepatic artery
and bile duct anastomoses were not complete. Patient was becoming
hemodynamically unstable requiring small boluses of epinephrine to maintain
blood pressure. The transplant surgery team decided that they could not
finish the surgery and the patient’s abdomen was packed. He was taken to the
pediatric intensive care unit where he died 3 hours later.
Fluid totals for the surgery were 107 units of packed red blood cells, 130
units of fresh frozen plasma, in excess of 200 units of cell saver blood, 50
units of platelets, and 17 liters of crystalloid. Pathology of the explanted
liver showed moderate cirrhosis and hepatic venous outflow obstruction.
Autopsy examination revealed an old thrombus in the hepatic vein.
Conclusion: Repeat liver transplants are very high risk surgeries because of
adhesions and the technical difficulty of the surgery. This case report
demonstrates that ongoing bleeding during repeat liver transplantation may
not be caused by a coagulopathy but may be attributed to other causes, such
as a unrecognized hepatic vein thrombosis.