Changes in hemostasis during orthotopic liver transplantation (OLT) and an intraoperative bleeding complication requiring massive transfusion are discussed. METHODS The monitoring of hemostasis included bed-sided thromboelastography, measurement of in vitro platelet function with the thrombostat and routine coagulation tests as well as retrospective analysis of coagulation factors. RESULTS Changes in hemostasis during OLT were documented as reported previously until reperfusion of the donor organ. Due to an incongruence between the caval veins and massive surgical bleeding, the liver had to be clamped again for reconstruction and perfused with University-of-Wisconsin solution. The second reperfusion was technically uncomplicated. However, the coagulation profile deteriorated dramatically: especially a decrease in platelet function and hyperfibrinolysis led to massive oozing. Successful therapeutical intervention included substitution of packed red blood cells. fresh frozen plasma, platelets. concentrates of hemostatic factors, and aprotinin. The patient was discharged from hospital after 5 weeks with a good liver function and a normal coagulation profile. CONCLUSIONS During OLT, clinically relevant changes in hemostasis can occur suddenly. Therefore. a close perioperative monitoring of primary and secondary coagulation is mandatory.