GastrointestinalIs central venous pressure still relevant in the contemporary era of liver resection?
Introduction
Recent advances in perioperative care and surgical technique for liver resection have significantly improved outcomes, with mortality rates now ranging from 0%–5% [1]. Intraoperative blood loss remains a concern during liver resection, leading to use of perioperative red blood cell transfusions (RBCTs) in 17%–40% of cases [2], [3], [4], [5]. Beyond risks of transfusion-related reactions and infection transmission, RBCTs are associated with worse outcomes including infection, morbidity, mortality, and even cancer recurrence [6], [7], [8], [9], [10], [11]. The National Summit on Overuse of the American Medical Association and the Choosing Wisely Campaign identified RBCT as an overused treatment to be targeted in efforts to improve patient outcomes [12], [13]. Optimization of RBCT use is important from both patient outcome and resource utilization perspectives [14], [15].
Better understanding of the factors associated with RBCT for hepatectomy in the contemporary era may focus efforts to decrease the use of transfusions. Major changes in perioperative management of liver resections have occurred and transformed care for these patients, including focus on limiting blood loss [16]. In this effort, low central venous pressure (CVP) anesthesia has emerged as a potentially effective strategy to decrease blood loss at the time of parenchymal transection [2], [3], [17].
We sought to assess preoperative and intraoperative factors associated with perioperative RBCT for liver resection, with a focus on modifiable intraoperative hemodynamic parameters, including CVP. In particular, we hypothesized that intraoperative CVP was independently associated with the need for perioperative RBCT.
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Methods
We performed a retrospective review of our prospective hepatectomy database, with a mandated detailed review of anesthetic records. This study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board.
Results
Among 851 liver resections performed during the study period, 530 patients underwent intraoperative CVP monitoring and were included in this study. Patients with intraoperative CVP monitoring were more likely to present with preoperative anemia (P < 0.0001), receive chemotherapy before resection (P = 0.01), and undergo a major liver resection (P < 0.0001; Table 1). Of included patients, 30.2% (n = 161 of 530) received RBCT. Of all patients transfused, 28.1% (n = 82 of 161) received RBCT
Discussion
In this series of patients undergoing liver resection with hemodynamic monitoring, we examined predictors of perioperative RBCT to identify modifiable factors to minimize blood product use. RBCT was mainly driven by preoperative anemia (P = 0.008), operative time (P = 0.03), and intraoperative CVP (P = 0.005). We highlighted a significant difference in intraoperative CVP evolution based on RBCT status (P = 0.007).
Transfusion rates after hepatectomy have varied from 17%–40% in prior research,
Conclusions
In summary, this study found that perioperative RBCT for liver resection is independently associated with female gender, preoperative anemia, longer operative time, and higher intraoperative CVP. A comprehensive, multidisciplinary, and standardized approach to blood conservation in liver resection is warranted, focusing on preoperative identification and management of anemia, operative efficiency, and maintenance of low intraoperative CVP. Close collaboration between surgical, anesthetic,
Acknowledgment
The authors acknowledge Iryna Kulyk and Jessica Truong for their contributions to this article.
All authors contributed significantly in the conception and design, critical editing, and approval of the current version of the article to be published of the study. S.S.H., C.H.L.L., N.G.C., J.T., Y.L., and P.J.K. contributed significantly in identifying patients who met criteria to be included in the study. E.S.W.C. and J.H. reviewed the charts and inputted the data into a database. All authors
References (38)
- et al.
Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy
J Am Coll Surg
(2007) - et al.
Minimising blood loss and transfusion requirements in hepatic resection
HPB
(2002) - et al.
Factors in perioperative care that determine blood loss in liver surgery
HPB
(2012) - et al.
Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction
J Am Coll Surg
(1998) - et al.
Predictors of blood transfusion requirement in elective liver resection
HPB
(2010) - et al.
Use of a collagen-sealing device in hepatic resection: a comparative analysis to standard resection technique
HPB (Oxford)
(2006) - et al.
Association between central venous pressure and blood loss during hepatic resection in 984 living donors
Acta Anaesthesiol Scand
(2009) - et al.
The impact of perioperative iron on the use of red blood cell transfusions in gastrointestinal surgery: a systematic review and meta-analysis
Transfus Med Rev
(2014) - et al.
A risk score for predicting perioperative blood transfusion in liver surgery
Br J Surg
(2007) - et al.
Trends and risk factors for transfusion in hepatopancreatobiliary surgery
J Gastrointest Surg
(2013)
Operative blood loss independently predicts recurrence and survival after resection of hepatocellular carcinoma
Ann Surg
Negative effects of transfused blood components after hepatectomy for metastatic colorectal cancer
Am Surg
Perioperative complications influence recurrence and survival after resection of hepatic colorectal metastases
Ann Surg Oncol
Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis
J Trauma Inj Infect Crit Care
The impact of perioperative red blood cell transfusions on long-term outcomes after hepatectomy for colorectal liver metastases
Ann Surg Oncol
Perioperative blood transfusions and recurrence of colorectal cancer
Cochrane Database Syst Rev
Experience of a network of transfusion coordinators for blood conservation (Ontario Transfusion Coordinators [ONTraC])
Transfusion
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Part of this study has been accepted for poster presentation at the 2014 Canadian Surgery Forum of the Canadian Association of General Surgeons, in Vancouver, British Columbia, Canada.