Sarah Bos

74 CHAPTER 5 develop a hypercoagulable state during surgery, which may contribute to the development of intraoperative or early postoperative thrombotic complications. (45) Intraoperative hypercoagulability was particularly frequent in patients with cholestatic disease, acute liver failure, and nonalcoholic steatohepatitis.(45) Prevention and Treatment of Bleeding Hepatic resection is often accompanied by intraoperative blood loss primarily occurring during parenchymal transection or tumor resection. Similarly, liver transplantation may also cause excessive blood loss during surgery, which may lead to increased postoperative morbidity and mortality.(89) There are several approaches available to attempt to reduce intraoperative blood loss, as will be outlined below. Central to our strategy to minimize blood loss is a restrictive fluid infusion policy. Multiple studies have demonstrated that maintenance of a low central venous pressure (CVP) and even a preoperative reduction of CVP by phlebotomy is a beneficial strategy in minimizing blood loss during hepatectomy or liver transplantation.(58,59,90,91) Our fluid restrictionmanagement includes the absence of routine prophylactic correction of abnormal coagulation tests (PT or point-of- care). Indeed, routine correction of abnormal coagulation tests with an infusion of fresh frozen plasma (FFP) is not effective in reducing intraoperative blood loss.(5,90) Moreover, preoperative coagulation tests have proven to be very poor predictors of intraoperative bleeding as reviewed in detail by Larsen et al in this issue.(92) Treatment of bleeding during liver surgery traditionally consists of transfusion of FFP, fibrinogen concentrate or cryoprecipitate, and platelet concentrates guided by routine diagnostic test or point-of-care testing. Transfusion of large amounts of FFP may, in fact, be counterproductive as it leads to fluid overload and a subsequent increase in the central and portal venous pressure, which is already elevated in many cirrhotic patients. Prothrombin complex concentrate (PCC) may be used as an alternative to FFP. PCC is a low-volume plasma product that contains selected procoagulant proteins and the anticoagulant proteins S and C. The advantage of PCCs over FFP is the low volume and the potential to fully normalize factor levels, while the disadvantage is that PCCs do not contain all procoagulant factors. A recent single-center retrospective study of liver transplant recipients showed that a ROTEM (Tem International GmbH, Munich, Germany)-based approach to administering PCCs and/or fibrinogen concentrate was safe and effective as compared with an FFP/platelet concentrate-based approach.(93) Another low-volume prohemostatic, recombinant factor VIIa (rFVIIa) has been trialed in liver transplantation. A meta- analysis on the use of prophylactic rFVIIa during hepatic surgery, however, did not show efficacy on perioperative bleeding.(94) Although in this meta-analysis rFVIIa did not show an increase in the risk for thromboembolic events, the thrombotic risk