*Purpose: Liver dysfunction results in derangement of hemostasis and thrombosis. Thromboelastography (TEG) has emerged as a tool to guide resuscitative efforts. However, its utilization and application in liver transplant (LT) surgery are not well determined. We aim to identify possible effects of TEG utilization on product use and blood loss in LT.

*Methods: Adult patients (age >18 years of age) who received LT between 2014 and 2020 were retrospectively reviewed. Those patients who underwent living donor, simultaneous or multi-organ transplants, re-transplants, and pediatric transplants (recipient <18 years of age) within this timeframe were excluded. Possible impact of TEG implementation on blood product use and intraoperative blood loss was analyzed. A subgroup analysis was done based on INR at transplant. The median, 75th, and 90th percentile of INR at transplant were used as cut-off values and patients were classified into four categories: no coagulopathy, mild, moderate, and severe coagulopathy groups.

*Results: A total of 451 patients met inclusion criteria and were separated into TEG (n=144) vs non-TEG (n=307) groups. Background characteristics between these two groups were comparable. Overall, median blood products used were similar between TEG and non-TEG groups: pRBC (4[IQR 2-6] U vs 3[1-7] U, p=0.194); FFP (6[3-10] U vs 6[2-11] U, p=0.697); Cryoprecipitate (1[0-2] U vs 1[0-3] U, p= 0.954); platelet (1[0-2] U vs 0[0-2] U, p= 0.065). In the subgroup analysis, there was a significant decrease in product use in the TEG group with moderate coagulopathy, compared to the non-TEG group: pRBC (4.5[2.0- 6.8] U vs 7.0[6.0-10.0] U, p= 0.002); FFP (6.0[4.0-8.0] U vs 9.0[8.0-16.0] U, p=0.005); Cryoprecipitate (1.0[1.0-2.0] U vs 2.0[1.0-4.0] U, p=0.005). Tranexamic acid (TXA) use was significantly higher in the TEG group with median values of 1000 [0-1500] mg vs 0 mg (p<0.001). There was no difference in median blood loss 2750 [1200-5250] ml vs 3500 [2125-7750] ml (p=0.09). In the no, mild, and severe coagulopathy groups, there was no difference in blood product use, blood loss, or TXA use between the TEG and non-TEG groups.

*Conclusions: TEG guided hemostasis and resuscitation in LT resulted in a decrease in product usage, as well as more utilization of TXA, likely by recognition of hyper-fibrinolysis, in patients with moderate coagulopathy defined as INR between 2.2 and 2.8.

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