Gastrointestinal
Is central venous pressure still relevant in the contemporary era of liver resection?

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Abstract

Background

Perioperative red blood cell transfusion (RBCT) remains common after liver resection and carries risk of increased morbidity and worse oncologic outcomes. We sought to assess the factors associated with perioperative RBCT after hepatectomy with a focus on intraoperative hemodynamics.

Methods

We performed a retrospective review of our prospective hepatectomy database, supplemented by a review of anesthetic records of all patients undergoing hepatectomy with hemodynamic monitoring (arterial and central venous pressures [CVP]) from 2003–2012. Primary outcome was perioperative RBCT (during and within 30 d after surgery). After descriptive and univariate comparisons, multivariate analysis was conducted to identify factors associated with RBCT.

Results

Of 851 hepatectomies, 530 had complete hemodynamic data and 30.2% (161 of 530) received RBCT. Among transfused patients, female gender (P = 0.01), preoperative anemia (P < 0.001), and major liver resection (P = 0.02) were more common. Mean estimated blood loss was 1.1 L higher (2.0 versus 0.9 L; P < 0.001) and operating time was 1.1 h longer (5.8 versus 4.7 h; P < 0.001) in transfused patients. Trends in intraoperative CVP differed significantly based on transfusion status (P = 0.007). Independent factors associated with RBCT included female gender (odds ratio [OR], 2.27; P = 0.01), preoperative anemia (OR, 2.38; P = 0.03), longer operative time (OR, 1.19 per hour; P = 0.03), and higher intraoperative CVP at 1 h during surgery (OR, 1.10 per mm Hg; P = 0.005).

Conclusions

Likelihood of RBCT is independently associated with female gender, preoperative anemia, longer operative time, and higher intraoperative CVP. Focus on management of preoperative anemia, operative efficiency, and low intraoperative CVP is needed to minimize the need for RBCTs.

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.

Section snippets

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

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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.

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