Case Report: Managing coagulopathy in neonatal acute liver failure: insights from a case of rebalanced hemostasis and thromboelastography monitoring

Background Neonatal acute liver failure (ALF) is a rare, life-threatening condition often accompanied by complex coagulopathy. Managing this coagulopathy is challenging due to the limitations of conventional coagulation tests and the lack of pediatric-specific transfusion guidelines, often leading to empiric blood product use. Methods We present a detailed case report of a neonate with ALF of indeterminate etiology. Clinical and laboratory monitoring included serial conventional coagulation tests (PT, APTT, INR, fibrinogen, D-dimer), coagulation factor assays, and thromboelastography (TEG). The therapeutic management and response to blood product transfusions (fresh frozen plasma, cryoprecipitate, platelets) were documented over a one-month hospitalization. Results The patient exhibited severe and persistent abnormalities in standard coagulation parameters (prolonged PT/APTT, elevated INR, hypofibrinogenemia, and deficiency of factors II, V, VII, IX-XII, ATIII, PC, PS) alongside thrombocytopenia. In contrast, TEG revealed a normal reaction (R) time, but a reduced alpha-angle and maximum amplitude (MA). Despite 14 transfusions of fresh frozen plasma, conventional coagulation parameters showed minimal improvement. Conclusion This case illustrates the complexity of coagulation monitoring in neonatal liver failure. It underscores the significance of comprehensive global hemostasis assays, such as TEG, which may provide superior guidance for transfusion therapy and help prevent the unnecessary administration of blood products in non-bleeding neonates with ALF.