The Utility of Viscoelastic Testing in Guiding Intraoperative Transfusion Requirements in Pediatric Living Donor...

Blood transfusion, though essential, is associated with increased morbidity following liver transplantation (LT). In pediatric liver transplantation (PLT), where physiological reserves are limited, optimal blood component transfusion (BCT) is critical. While viscoelastic testing (VET) has shown benefits in adult LT, pediatric evidence remains limited and transfusion triggers are poorly defined. This study evaluated the effectiveness of VET-guided BCT in pediatric living donor liver transplantation (LDLT).

A prospective analysis was conducted on children undergoing LDLT between January and August 2024. Demographic, clinical, transfusion, and outcome data were collected. Conventional coagulation tests (CCTs) including platelet count, international normalized ratio, and fibrinogen along with rotational thromboelastometry (ROTEM) were assessed at three predefined intraoperative time points. Transfusion decisions were guided by VET parameters, clinical hemodynamics, and predefined triggers. Correlations between CCTs and ROTEM parameters were analyzed, and ROC analysis was used to determine ROTEM cutoffs for thrombocytopenia and hypofibrinogenemia.

Fifty pediatric recipients (median age 12 [8-56] months) were included. Mean intraoperative transfusion requirements were 27.6 ± 16.95 mL/kg for leuko-depleted packed red cells, 4.76 ± 7.29 mL/kg for fresh frozen plasma, and 4.78 ± 5.68 mL/kg for cryoprecipitate. Preoperative hemoglobin and hematocrit correlated significantly with red cell transfusion requirements (p < 0.01). Platelet count correlated with EXTEM maximum clot firmness (MCF) (r = 0.562), and fibrinogen levels correlated with FIBTEM MCF (r = 0.503) (p < 0.001). EXTEM MCF < 35 mm predicted platelet count < 50 000/μL, while FIBTEM MCF thresholds of 11 mm and 9 mm predicted fibrinogen levels < 150 and < 100 mg/dL, respectively.

VET is a reliable point of care tool for guiding transfusion in PLT, enabling targeted blood component use and potentially reducing transfusion-related morbidity.