Thrombocytopenia is a common complication of both chronic liver disease and liver transplantation (LT). The mechanism of thrombocytopenia is multifactorial implicating not only sequestration in the spleen, or in the graft, reduction in the mean platelet survival but also decreased platelet production due to low synthesis of thrombopoietin (TPO) or direct toxicity to the bone marrow. Platelets play a dualistic role in liver transplant, both beneficial and detrimental. The beneficial role of platelets is due to platelet-derived serotonin that is involved in liver regeneration. During surgery for liver transplant, in addition to the preoperative causes for thrombocytopenia, we have other mechanisms that will contribute to further deterioration of the platelets count and function: hemodilution, immunological reactions, and sequestration in the newly transplanted graft. This might result in a life-threatening level of thrombocytes. The concern is when we should treat thrombocytopenia because despite life-saving benefits, transfusion has also been related to complications and platelet transfusion has been identified as an independent risk factor for postoperative complications. Risks related to platelet concentrate administration are allergic reactions, alloimmunization, bacterial sepsis, and transfusion-related acute lung injury (TRALI). Administration of platelets is not indicated if there is no bleeding or immediate bleeding risk. New emerging therapies like thrombopoietin-receptor agonist will furthermore limit the administration of blood products.
Part of the book: Thrombocytopenia
Liver transplantation is a high-risk surgery performed on a high-risk patient and is the only treatment for end-stage liver disease. Ever since the first successful liver transplant performed, patient survival increased due to improvement of surgical technique and anaesthetic management as well as the emergence of new generations of immunosuppressants. The pre-anaesthetic evaluation is mandatory and plays an important role in patient inclusion on the transplant list. Liver transplantation is performed under general anaesthesia, and the anaesthetic monitoring is very important for a successful liver transplantation as it can expose problems before irreversible damage occurs. Haemodynamic instability is common during surgery, requiring complex invasive haemodynamic monitoring. Continuous assessment of the patient’s volemic status and the amount of perfused fluids represent the key to a successful liver transplantation. Inadequate fluid therapy can lead to pulmonary oedema, abnormal gas exchange, congestion, decrease in perfusion and oedema of the graft. Liver reperfusion takes place in the neohepatic phase and is the most unstable period during liver transplantation, representing a real challenge for the anaesthetist. It can have severe consequences due to a decrease in cardiovascular function with haemodynamic instability, abnormal acid base balance and metabolic abnormalities.
Part of the book: Organ Donation and Transplantation