Prothrombin complex concentrate use in liver transplantation: an international survey of current practices

Purpose: Prothrombin complex concentrate (PCC) is increasingly used for acquired coagulopathy in surgical patients, yet attitudes and usage patterns in liver transplantation are unclear. We sought to examine current practices of coagulopathy management during liver transplant surgery. Methods: We conducted a cross-sectional, international multi-centre survey of anesthesiologists, intensivists, and surgeons caring for patients undergoing liver transplantation. The survey included closed and open-ended questions and assessed PCC usage patterns. For analysis, we used descriptive statistics using counts and proportions. We analyzed qualitative data to identify themes describing PCC use and priorities for future clinical trials. Results: Originating from 10 countries, 107 respondents participated, primarily anesthesiologists (88%). Prothrombin complex concentrate was used by 42%, avoided by 28%, and reserved for rescue treatment by 30%. While frozen plasma (82%) was preferred over PCC (16%) as first-line treatment for general coagulation factor deficiency, 14% preferred to avoid plasma altogether. Intraoperatively, viscoelastic testing (85%) was preferred to guide transfusion management; nevertheless, 43% of respondents reported no use of standardized transfusion algorithms at their institution. While clinicians indicated hesitancy to administer PCC to patients with a perceived higher risk of thromboembolism, they also strongly expressed hesitancy to administer plasma to patients with volume overload. Conclusions: There is high variability in PCC use among clinicians administering transfusion in patients undergoing liver transplantation perioperatively. Clinicians perceived that PCC was likely beneficial for avoidance of volume overload, but a lack of comparative safety data to plasma was cited as a barrier to use. An adequately powered, high-quality randomized trial is required to guide evidence-based practice.