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Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease, which is often multifactorial and associated with hemostatic disturbances affecting both the procoagulant and anticoagulant systems. This rebalanced coagulation system may lead to bleeding diathesis or increased clot formation. Conventional coagulation tests cannot reflect these complex changes because they can only illustrate deficiencies in the procoagulant system. Viscoelastic tests such as rotational thromboelastometry (ROTEM) have been used in LT and have shown useful for detecting coagulopathy and guiding transfusions. Implementation of ROTEM-guided bleeding management algorithms has proven effectiveness in reducing bleeding, transfusion needs, complication rates, and healthcare costs in LT. This document is intended to provide a practice algorithm for the management of major bleeding and coagulopathy during LT and to encourage adaptation of the guidelines to individual institutional circumstances and resources.

Background: Reducing anesthesia-controlled time (ACT) such as extubation time may improve operation room (OR) efficiency result from different anesthetic techniques. However, the information about the difference in ACT between desflurane (DES) anesthesia and propofol-based total intravenous anesthesia (TIVA) techniques for open liver resection under general anesthesia is not available in the literature., Methods: This retrospective study uses our hospital database to analyze the ACT of open liver resection after either DES/fentanyl-based anesthesia or TIVA via target-controlled infusion (TCI) with fentanyl/propofol from January 2010 to December 2011. The various time intervals including waiting for anesthesia time, anesthesia time, surgical time, extubation time, exit from OR after extubation, total OR time, and post-anesthetic care unit stay time and percentage of prolonged extubation (≥ 15 minutes) were compared between the two anesthetic techniques., Results: We included 143 hepatocellular carcinoma patients, with 82 patients receiving TIVA and 61 patients receiving DES. The extubation time was faster (10.1 ± 3.2 min vs. 11.8 ± 5.2 min; P = 0.03), and the incidence of prolonged extubation was lower (9.8% vs. 26.8%; P = 0.02) in the DES group than in the TIVA group. The factors contributed to prolonged extubation were age, sex, anesthetic technique, and anesthesia time., Conclusion: The DES anesthesia provided faster extubation time and lower incidence of prolonged extubation compared with propofol-based TIVA by TCI in elective open liver resection. Besides, older age, male, TIVA, and lengthy anesthesia time were factors affecting prolonged extubation.

Shock is defined as hypoperfusion of tissues and/or organs. The initial focus of resuscitation following shock is on establishing an open airway and ensuring adequate ventilation and circulation. Causes of shock can be recognized quickly via clinical manifestations. A professional physical examination and observation of response to therapy can result in early diagnosis of the causes of unstable vital signs. Identification of shock symptoms in order to administer appropriate treatment quickly is key to saving patient lives, because "time is tissue". In all shock cases, treatments begin with an evaluation, resuscitation and immediate treatment of life-threatening symptoms. Patients may experience more than one kind of shock simultaneously, which further complicates their assessment and treatment. The critical care of shock should be done thoroughly and systematically in order to assess and manage patients so as to avoid dysfunctions in one organ damaging others. During emergency and critical management of shock patients, once a certain stage of assessment is completed, further evaluation is necessary to assess condition improvement. If improvement is confirmed, maintenance therapy may be considered. If improvement is not confirmed, it should be considered whether treatment is inadequate or misfocused, or whether the patient's response is atypically poor. In addition to timely resuscitation and ICU care, there are specific effective treatments for each type of shock. Such must be administered in accordance with guidelines, standard protocols and goal-oriented approaches. Trends in shock management currently focus on integrating guidelines, standard protocols and goal-oriented approaches into a "treatment bundle", which facilitates the implementation of clinical medical care and completes specific goals within a specified time limit to reduce the risk of multiple organ failure and death due to shock.