- Disseminated intravascular coagulation. - following air embolism during orthotropic liver transplantation: is this just a coincidence?. - Background: During orthotopic liver transplantation, venous air embolism may occur due to iatrogenic injury of the inferior vena cava. - However, venous air embolism followed by coagulopathy is a rare event. - In this case report, we discuss a possible connection between venous air embolism and disseminated intravascular coagulation.. - ted for orthotopic liver transplantation. - During the dissection phase of the surgery, arterial blood pressure, heart rate, saturation and end‑tidal carbon dioxide levels suddenly decreased, indicating the occurrence of venous air embolism.. - After stabilizing the patient’s condition, various coagulation issues started developing. - Venous air embolism‑induced coagulopathy was handled by administering transfusions of various blood products. - However, the patient’s condition continued to deteriorate leading to a complete asystole.. - Conclusions: This is a rare case of venous air embolism‑induced disseminated intravascular coagulation. - The real connection remains unclear as disseminated intravascular coagulation for end‑stage liver disease patients can be induced by various causes during different stages of liver transplantation. - Certainly, both venous air embolism and coagulopathy were significant and led to an unfavorable outcome. - Keywords: Venous air embolism, Disseminated intravascular coagulation, Liver transplantation. - Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. - The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. - If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. - 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.. - The first human orthotopic liver transplantation (OLT) was performed in 1963. - Despite the development of technology in the medical field, hepatic transplantation remains a difficult surgery and carries a risk of signifi- cant complications [1]. - One possible, although rare, but potentially fatal complication that occurs during ortho- topic liver transplantation is venous air embolism (VAE).. - It could be defined as the presence of air or carbon diox- ide in the inferior vena cava and right atrium, which leads to the obstruction of blood flow through the heart [2].. - Another well-known condition is coagulopathy, which is caused by liver disease and hemostatic changes during surgery [3] and can lead to the development of dissemi- nated intravascular coagulopathy (DIC). - In other words, the prevalence of DIC following venous air embolism remains unclear. - Full list of author information is available at the end of the article. - liver transplantation (OLT) to the Hospital of Lithuanian University of Health Sciences Kaunas Clinics. - CT CAP showed ground glass opacity (GCO) findings in the right lung. - In the anticipation of a high risk of bleeding group and save as well as crossmatch were requested prior operation. - In the operation theatre standard anes- thesia was induced with 2.8 mcg/kg fentanyl, 2.5 mg/kg propofol, and 0.14 mg/kg cisatracurium. - The patient was intubated with standard endotracheal tube no. - There was no hemodynamic instability during the initial portion of the procedure. - During the recipient hepatectomy (hour mark two), the patient had a sudden decrease in arterial blood pressure, heart rate, oxygen saturation and end-tidal carbon dioxide level. - The surgeons confirmed the presence of a defect in the inferior vena cava at its junction with hepatic veins, proving the preliminary diagnosis of venous air embolism. - Although adequate ventilation with a high inspired oxygen fraction was maintained, satura- tion remained low during the remaining portions of the surgical procedure. - however, further problems were more closely related to various coagulation issues which led to massive allogenic blood products and autologous blood transfusion and the development of DIC. - The urgent call of blood products was indicated – the total amount of transfused blood during the surgery was 10,955 ml (49 units) alongside 14,000 ml of fluids to maintain volemia. - The patient was transfused continu- ously using various blood products according to local transfusion protocols and viscoelastic blood coagula- tion test results (Fig. - 28 × 10 9 /l) due to the lack of fibrinogen, and proper clot formation could not be achieved (Fig. - During the other phases of the surgery, the patient received protective lung ventilation (Vt of 6–8 ml/kg IBW and PEEP at 8 cm H 2 O) with a high inspired oxygen Fig. - The patient remained in a critical condi- tion and was transferred to the ICU for further treat- ment. - Diffuse bleeding almost immediately after transplanta- tion, on first postoperative day, from the upper abdomen and thrombosis of the hepatic artery were suspected as the patient’s anaemia worsened and transaminase levels increased. - Contrast extravasation was also noted in the venous phase. - The patient was taken back to the Operating Theatre for exploration which demonstrated 3000 ml of blood (fresh and clotted). - After the patient’s second laparotomy, he continued to deteriorate and required increasing doses of vasopressors to maintain adequate blood pressure and tissue perfu- sion. - Circulatory and metabolic problems associated with liver transplantation (LT) have been an issue since the begin- ning of these kinds of surgeries, despite improvements in surgical and anesthetic techniques [3]. - During the anhepatic phase, no hepatic clotting factors are produced, fibrinogen is depleted and antithrombin concentrations decrease, leading to worsening coagulopathy and the onset of fibrinolysis.. - Hyperfibrinolysis is detected in 30 to 46% of patients who have end-stage liver disease [2]. - It may occur due to the reduced clearance of t-PA. - Despite the fact that fibrinogen levels in end-stage liver disease (ESLD) are typically normal or elevated, most of the proteins are dysfunc- tional due to abnormal molecular structure [10]. - 3 The dynamics of blood transfusion rates during the perioperative period. - 2 (4 am–6 am). - However, during the time this case occurred, fibrinogen was not officially registered in our country, making fibrinogen replacement therapy diffi- cult or even impossible to administer. - Unfortunately, this benchmark failed to be achieved during the surgery (Fig. - There is another possible explanation for abnormal coagulation in this case as the patient experienced car- diac arrest immediately after the episode of venous air embolism. - In the early phase of PCAS, hyperfibrinolysis is followed by inade- quate fibrinolysis and fibrinolytic shutdown [15].. - Dilutional thrombocytopenia as an adverse effect of massive blood transfusion exacerbate preoperative thrombocytopenia in patients with chronic liver disease [16]. - Additionally, it is important to mention an imbal- ance in pro- and anticoagulation factors in the plasma of cirrhotic patients, as the plasma of these patients’ is resistant to thrombomodulin, which is the main activa- tor of the protein C anticoagulant pathway, resulting in hypercoagulability [17]. - VETs provide informa- tion about the kinetics of clot formation and the strength of the clot and distinguish contributions from fibrinogen, platelets and the fibrinolytic system [19].. - The leading causes of air embolism are mostly mechan- ical defects caused by surgery, trauma, vascular inter- ventions and barotrauma from mechanical ventilation or, rarely, diving [20]. - Although air embolus is not an uncommon complication, there are only a few case reports of massive air embolus during orthotopic liver transplantation. - In our case, a defect in the hepatic vein and IVC confluence occurred during the dissection phase of the operation. - Unfortunately, we could not obtain access to the characteristics of used liver graft.. - DIC following air embolism during orthotopic liver transplantation is a rare case, and only a few studies have investigated the possible connection between these two complications. - A study with animals revealed that platelet aggregation and the release of plasminogen-activator inhibitors can be a result of the formation of microbubbles [30]. - In our case, the reason for intraoperative coagulopathy might have been hypovolemia, although fluid resuscitation is limited in LT patients, especially during the dissection phase.. - Both our case and this case share the same cause of VAE, which was a surgical trauma in the venous system. - One of the contributing factors in our case is a lack of effective communication between the surgeon and the anesthetist. - In 2013, a study conducted in India revealed that 52,2% of the surveyed anesthesiologists felt that poor communication between the surgeon and anesthesiolo- gist affected the outcome [32]. - Only the acknowl- edgment of personal flaws, tactfulness and communi- cation with colleagues can lead to safe, confident and patient-oriented teamwork in the operating room.. - Although coagulopathy following venous air embolism has been reported in a small number of cases, it should not be underestimated, as some complications, although rare, may be life-threatening. - ESLD: End‑stage liver disease. - LT: Liver transplantation. - OLT: Orthotopic liver transplantation. - VAE: Venous air embolism. - KA was a major contributor to writing the discussion section of the manu‑. - GV analyzed the patient data regarding end‑stage liver disease and liver transplantation and was a contributor to creating tables and figures. - The datasets generated and analyzed during the current study are not publicly available due to preservation of the individual’s privacy under the European General Data Protection Regulation but are available from the corresponding author on reasonable request.. - According to the Lithuanian Bioethics Committee, if the person’s illness case will be presented in a journal in a way in which the patient’s identity is not directly or indirectly revealed, the Legal Acts do not require consent from the patient. - Written informed consent was obtained from the patient’s relative for publication of this case report and any accompanying images as the patient is deceased. - Evolution of liver transplantation.. - Haemostatic disorders during liver transplantation. - Effect of liver disease etiology on ROTEM profiles in patients undergoing liver transplantation. - Transfusion and coagulation management in liver transplan‑. - Intraoperative cell salvage with autologous transfusion in liver transplantation. - The Fibrinolytic status in liver diseases. - rhage in liver transplantation: consequences, prediction and manage‑. - Coagulation management during liver transplantation: use of fibrinogen concentrate, recombinant activated factor VII, Prothrombin complex concentrate, and antifibrinolytics. - Hemostasis in liver transplantation:. - Coagulopathy in liver disease: lack of an assessment tool. - Concepts and controversies in Haemostasis and thrombosis associated with liver disease: proceedings of the 7th international coagulation in liver disease conference. - Air embolism. - Air Embolism and Anaes‑. - Diagnosis and treatment of vascular air embolism. - Transesophageal echocardiography during Orthotopic liver transplantation: maximizing information without the distraction. - A comprehensive review of transesophageal echocardiography during Orthotopic liver transplanta‑. - able benefit of the pulmonary artery catheter after cardiac surgery in high‑risk patients. - Venous air embolism induces both platelet dysfunction and thrombocytopenia.. - Air embolism as a cause of the systemic inflamma‑. - Coagulopathy following venous air embolism: a disastrous consequence ‑a case report. - Critical role of the surgeon‑anesthesiologist relationship for patient safety
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