Quantitative and Qualitative Hemostatic Response Assessed by ROTEM After Fibrinogen Concentrate and Platelet...

Patients undergoing liver transplantation experience dynamic alterations in hemostasis, as impaired fibrinogen synthesis, dysfibrinogenemia, hemodilution, and ongoing surgical bleeding collectively impair clot formation and strength. Fibrinogen abnormalities involve both quantitative deficiency and qualitative dysfunction. We report the case of a 70-year-old male with a Model for End-Stage Liver Disease (MELD) score of 36 who underwent orthotopic liver transplantation for acute liver failure following a cholecystectomy. During the reperfusion phase, diffuse oozing was noted with a plasma fibrinogen of 100 mg/dL and ROTEM-FIBTEM maximum clot firmness (MCF) of 6 mm. An initial 2 g dose of fibrinogen concentrate raised plasma fibrinogen to 150 mg/dL but resulted in only a minimal increase in FIBTEM MCF to 7 mm. A subsequent 2 g dose increased plasma fibrinogen to 175 mg/dL and restored FIBTEM MCF to 13 mm, within the normal range. EXTEM MCF approached the reference range only after one bag of platelet transfusion, suggesting concurrent qualitative platelet impairment. After these interventions, bleeding clinically ceased, and there were no hemorrhagic complications postoperatively. These findings underscore the importance of combined serial quantitative and qualitative hemostatic assessment to guide transfusion management during liver transplantation.