Epsilon-aminocaproic acid for treatment of fibrinolysis during liver transplantation

Abstract

In 97 adult patients receiving liver transplants, the coagulation system was monitored by thrombelastography and by coagulation profile including PT; aPTT; platelet count; level of factors I, II, V, VII, VIII, IX, X, XI, and XII; fibrin degradation products; ethanol gel test; protamine gel test; and euglobulin lysis time. Preoperatively, fibrinolysis defined as a whole blood clot lysis index of less than 80% was present in 29 patients (29.9%), and a euglobulin lysis time of less than 1 h was present in 13 patients. Fibrinolysis increased progressively during surgery in 80 patients (82.5%) and was most severe on reperfusion of the graft liver in 33 patients (34%). When whole blood clot lysis (F less than 180 min) was observed during reperfusion of the graft liver, blood coagulability was tested by thrombelastography using both a blood sample treated in vitro with epsilon-aminocaproic acid (0.09%) and an untreated sample. Blood treated with epsilon-aminocaproic acid showed improved coagulation without fibrinolytic activity in all 74 tests. When whole blood clot lysis time was less than 120 min, generalized oozing occurred, and the effectiveness of epsilon-aminocaproic acid was demonstrated in vitro during the pre-anhepatic and post-anhepatic stages, epsilon-aminocaproic acid (1 g, single intravenous dose) was administered. In all 20 patients treated with epsilon-aminocaproic acid, fibrinolytic activity disappeared; whole blood clot lysis was not seen on thrombelastography during a 5-h observation period, and whole blood clot lysis index improved from 28.5 +/- 29.5% to 94.8 +/- 7.4% (mean +/- SD, P less than 0.001). None of the treated patients had hemorrhagic or thrombotic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Fig. 1

Schematic diagram of thrombelastography.

Fig. 2

Variables measured by thrombelastography and their normal values: r = reaction time (min); r + k = coagulation time (min); α = clot formation rate (°); MA = maximum amplitude (mm); A₆₀ = amplitude 60 min after maximum amplitude (mm); F = whole blood clot lysis time (min); and WBCLI = whole blood clot lysis index (A₆₀/MA·100, %).

Fig. 3

Relation between whole blood clot lysis time (F) and euglobulin lysis time (ELT) in patients who demonstrated fibrinolysis. The correlation was poor (r² = 0.29).

Fig. 4

Thrombelastographic patterns in a patient undergoing liver transplantation. ε-aminocaproic acid (EACA, 1 g) was administered intravenously when severe fibrinolysis was observed on thrombelastography, generalized oozing occurred in a previously dry surgical field and EACA treated fibrinolysis in vitro.