Haemostatic management for aortic valve replacement in a patient with advanced liver disease  

作　　者：Laurence Weinberg Irene Kearsey Clarissa Tjoakarfa George Matalanis Sean Galvin Scott Carson Rinaldo Bellomo Larry McNicol Peter McCall 

机构地区：[1]Department of Anaesthesia, Austin Hospital,Melbourne, Victoria 3084, Australia [2]Department of Cardiac Surgery, Austin Hospital,Melbourne, Victoria 3084, Australia [3]Department of Intensive Care, Austin Hospital,Melbourne, Victoria 3084, Australia

出　　处：《World Journal of Clinical Cases》2014年第10期596-603,共8页世界临床病例杂志

基　　金：Supported by Department of Anaesthesia Research Fund,Department of Anaesthesia,Austin Hospital,Melbourne,Victoria 3084,Australia

摘　　要：Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, plate-let activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like "post-perfusion-syndrome" also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, plate-let activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like "post-perfusion-syndrome" also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.

关 键 词：CARDIAC surgery LIVER failure COAGULOPATHY CARDIOPULMONARY BYPASS 

分 类 号：R654.2[医药卫生—外科学]