What is it about?

Patients undergoing liver transplantation (LT) have an abnormal clotting process, leading to either torrential bleeding or excessive clotting. Accurate and rapid bedside viscoelastic monitoring (VEM) tests such as ROTEM and TEG can help delineate the specific clotting abnormality that needs to be corrected. The four significant corrections usually required during LT are: drugs to treat excessive blood clot lysis, fresh frozen plasma or Prothrombin concentrate for slow clot initiation, fibrinogen or cryoprecipitate for slow clot progression and platelets for a weak clot. Additional modifications in the VEM can further diagnose complicated clotting problems. Representative clinical scenarios where VEM findings have helped manage abnormal clotting at various stages of LT are presented in the supporting figures. Multiple studies over the past two decades have shown that VEM during LT reduces unnecessary blood component transfusions, even though they might not affect the overall outcomes. Clinicians should recognize that VEM is only a tool, and decision-making should be based on the patient’s clinical condition. An abnormal VEM in itself should not trigger a correction in the absence of clinically significant bleeding.

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Why is it important?

Increased bleeding and blood product transfusion during liver transplantation (LT) can lead to significant complications such as infections, reoperations, extended intensive care unit stay, higher rates of graft failure, and patient mortality. Viscoelastic monitoring (VEM) provides the closest simulation of the blood clotting process inside the body. It thus helps make an accurate assessment of clotting in operation theatres and intensive care units. While clinicians are very familiar with conventional clotting tests such as platelet count, prothrombin time etc., VEM technologies might still be a mystery box. This review discusses the critical role of VEM in LT. It provides a primer for interpreting VEM to make real-world clinical decisions.


Coagulation is often a misunderstood subject, especially in the liver transplant setting. The availability of newer technologies such as viscoelastic monitoring (VEM) needs to be leveraged to improve the clinical outcomes. We have been using VEM extensively for more than a decade. We have found them to be clinically reliable and effective. I hope this article leads more clinicians to fully utilize VEM to understand and successfully manage the complex coagulation patterns during liver transplantation.

Selvakumar Malleeswaran
Gleneagles Global Health City, Chennai, India

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This page is a summary of: Viscoelastic Monitoring in Liver Transplantation, Liver Transplantation, December 2021, Wiley, DOI: 10.1002/lt.26352.
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