Building on previous reviews, the authors again want to highlight the latest updates in liver transplantation relevant to anesthesiologists. Machine perfusion has increased the number of available organs for transplantation. In addition to ex vivo machine perfusion, normothermic regional perfusion has demonstrated good outcomes for patients. However, there remain ethical considerations that anesthesiologists should be aware of. Prompt extubation in pediatric liver transplant patients improves outcomes. To be successful, anesthesiologists should build a strong institutional framework with all stakeholders. Extracorporeal membrane oxygenation utilization in liver transplantation can support patients with comorbidities or in emergent situations, albeit with significant risk of morbidity. Finally, the use of factor concentrates, including fibrinogen concentrates and prothrombin complex concentrates, is an emerging treatment modality for coagulopathy associated with advanced liver disease.

Perioperative hemorrhage during cardiac surgery is a frequent occurrence and can result in significant morbidity and mortality for patients. Prothrombin complex concentrate (PCC) and recombinant factor VIIa (rFVIIa) are therapies that have been used extensively in cardiac surgery with some promise, but with some concern around acute kidney injury (AKI) and thromboembolic disease with rFVIIa use. In this meta-analysis and systematic review, the authors summarize the evidence regarding the effects of PCC and rFVIIa on chest tube output, incidence of adverse events, and mortality of adult patients undergoing cardiac surgery. A total of 962 patients from seven retrospective observational studies were included in the pooled analysis. There was a significant reduction in the primary outcome: total chest tube output (mean difference: -301.01 mL, 95% confidence interval [CI] -550.54 to -51.48). PCC was associated with a significant reduction in total thromboembolic disease (odds ratio: 0.55, 95% CI 0.34 to 0.89), deep vein thrombosis (odds ratio 0.28, 95% CI 0.15 to 0.52), and cryoprecipitate transfusion (mean difference: -3.93, 95% CI -7.64 to -0.21). There were no significant differences between groups in the incidence of AKI or mortality. Five studies were deemed at moderate risk of bias, and two at serious risk. PCC has been shown to have a beneficial effect on reducing chest tube output and incidence of thromboembolic disease, with no increase in AKI compared with rFVIIa.

Factor Xa inhibitors (FXaI) are increasingly used for anticoagulation therapy, yet their association with intracranial hemorrhage poses a significant challenge. Although andexanet alfa (AA) and four-factor prothrombin complex concentrate (4F-PCC) have shown promise in reversing FXaI effects, their comparative efficacy and safety remain uncertain. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a literature search on electronic databases to obtain the relevant studies until May 16, 2024. Our primary outcomes were successful anticoagulation reversal, overall mortality (including 30-day and in-hospital mortality), and thromboembolic events. Secondary outcomes were length of hospital and intensive care unit stay and hematoma volume expansion. Data were pooled using a random-effects model. We included 16 eligible studies with a total of 2,977 patients. A statistically significant improvement in hemostatic efficacy rates was in favor of the AA group (risk ratio [RR] 1.10, 95% confidence interval [CI] 1.01-1.20, P = 0.02). Lower overall mortality rates were found in the AA group (RR 0.67, 95% CI 0.51-0.88, P = 0.004). However, no difference was found in 30-day mortality rates (RR 0.82, 95% CI 0.58-1.16, P = 0.26). In terms of thromboembolic events, more events were found in the AA group (RR 1.47, 95% CI 1.01-2.15, P = 0.046). AA was associated with a longer duration of hospital stay compared to 4F-PCC (mean difference [MD] 0.64, 95% CI 0.07-1.22, P = 0.03). Neither a significant difference in length of intensive care unit stay (MD 0.25, 95% CI - 0.36 to 0.86, P = 0.41) nor a significant difference in hematoma volume expansion was reported (MD - 0.89, 95% CI - 3.11 to 1.34, P = 0.435). Our results suggest that AA is superior to 4F-PCC in enhancing the hemostatic efficacy and reducing the overall and in-hospital mortality rates. More thromboembolic events are thought to be associated with the use of AA. However, more studies are required to validate whether the better results of AA in improving hemostatic efficacy are enough to make up for their higher cost and their possible risk of thromboembolic events.

Reduced thrombin generation is an important component of post cardiopulmonary bypass (CPB) coagulopathy. To replenish coagulation factors and enhance thrombin generation in bleeding surgical patients, frozen plasma (FP) and four-factor prothrombin complex concentrate (4F-PCC) are used. However, the efficacy-safety balance of 4F-PCC relative to FP in cardiac surgery is unconfirmed.