© Springer International Publishing AG Switzerland 2015
Luca Aldrighetti, Francesco Cetta and Gianfranco Ferla (eds.)Benign Tumors of the Liver10.1007/978-3-319-12985-3_2424. Blood and Transfusion Management in Liver Surgery
(1)
Department of HPB and Transplantation Surgery, Royal Prince Alfred Hospital, Missenden Road, Sydney, NSW, 2050, Australia
Keywords
Blood transfusionAutologous blood donationPreoperative managementIntraoperative managementPostoperative management24.1 Introduction
Despite the significant progress made in the field of liver surgery, intraoperative blood transfusion is still required in 10–30 % of patients undergoing elective liver resection for benign tumors [1–3]. Transfusion of allogeneic (donated from another individual) blood is associated with an increased perioperative morbidity and possibly tumor recurrence, as well as carrying the inherent risk of transfusion-transmitted viral infections [1, 4]. In order to reduce the use of allogeneic blood, several pharmacological, anesthetic and surgical interventions have been tried with variable success. The decision to transfuse any patient for a given indication must balance the risks of not transfusing. While guidelines vary between centers and also between individual clinicians, generally accepted guidelines suggest that blood transfusion be considered at hemoglobin values <70 g/L, with a higher threshold (<90 g/L) reserved for patients with cardiovascular disease, or those suspected to have covert cardiovascular disease [5].
24.2 Predicting the Need for Blood Transfusion
Having an accurate method of predicting the need for blood transfusion preoperatively is useful when ordering allogeneic blood but particularly in the context of preoperative autologous blood donation (PABD).
The number of units of autologous blood obtained before surgery is most commonly based on the amount that would be cross matched before surgery if allogeneic blood were being used [6]. Algorithms have been proposed to stratify patients according to the likelihood of requiring transfusion, based on the preoperative hemoglobin level and type of operation planned [7]. However, an important limiting factor for this nonspecific approach is that similar surgical procedures can be accompanied by different amounts of blood loss. This concept is particularly important in liver surgery, where blood loss can range from a few milliliters to over 10 L [8].
Attempts have been made to predict the need for blood transfusion in liver surgery. We have previously identified 5 variables associated with blood transfusion which included preoperative hemoglobin concentration below 12.5 g/dl, largest tumor greater than 4 cm, need for exposure of the vena cava, need for an associated procedure, and cirrhosis. Using these variables we have developed a transfusion risk score highly predictive of the likelihood of needing blood transfusion [1]. A similar study from Cockbain et al. identified seven factors predictive of transfusion: coronary artery disease, hemoglobin <12.5 g/dL, preoperative biliary drainage, largest tumor greater than 3.5 cm, redo resection, cholangiocarcinoma, and extended resection. These studies have demonstrated that blood transfusion can be predicted with a high degree of accuracy [9]. These scores can be useful in order to estimate the amount of units likely to be required for preoperative cross matching or the need for PABD.
24.3 Preoperative Management
The patient’s status should be optimized to reduce the risk of allogeneic transfusion. All patients undergoing liver resection should have a full blood count performed prior to surgery, and those patients presenting with anemia should be investigated and treated appropriately. Coagulation should be evaluated with a platelet count and clotting studies and corrected if necessary. Medication such as antiplatelet and anticoagulant drugs should be considered and stopped if the risk of bleeding outweighs the risk of discontinuing these drugs. Optimization of nutritional status with supplemental enteral feeding is usually not necessary in case of benign tumors, but can be considered in selected cases.
The use of PABD was once promoted to decrease allogeneic transfusion requirements but is only recommended when the risk of blood transfusion is more than 50 % [6]. The main advantage of PABD is avoiding exposure to allogeneic blood. However, PABD can only be considered when it is possible to guarantee admission and operative dates.
Preoperative hemoglobin levels can be improved in some patients with vitamin deficiencies by the use of pharmacological intervention such as iron, folate, and vitamin B12. Erythropoietin can also be considered and should be targeted at patients under 70 years of age who are scheduled for major liver resection and who have a presenting hemoglobin <130 g/l. Erythropoietin can also be used successfully in combination with PABD [10]. However, the efficacy and cost-effectiveness of preoperative erythropoietin and autologous blood donation to reduce allogeneic blood transfusion are still being debated, and their use remains limited [11].
24.4 Intraoperative Management
In the intraoperative period, measures should be aimed at decreasing blood loss and blood transfusion requirements. Low central venous pressure (<5 cm H2O) is commonly used in liver surgery because it is thought to reduce hepatic venous pressure, resulting in a decrease in blood loss [8]. However, a recent meta-analysis concluded that low CVP reduces blood loss and fresh frozen plasma (FFP) requirements but not red cell transfusion requirements [12]. Hypoventilation through the reduction of tidal volume has been used as a method for decreasing blood loss because of its role in decreasing the CVP. However, the efficacy of this anesthetic technique remains controversial [13].
Acute normovolemic hemodilution (ANH) has been used to reduce the requirement of allogeneic blood [12]. The procedure consists in the removal of blood from the patient immediately before operation and replacement with a synthetic colloid. The removed blood is then reinfused as autologous whole blood later during the procedure. This method has several advantages: it is inexpensive, the chance of clerical error is reduced, and blood withdrawn during ANH does not undergo biochemical alterations unlike stored predonated autologous blood [14].
The use of cell salvage in liver surgery has been limited by the hypothetical risk of aspirating and reinfusing tumor cells to the patient and the supposed lower quality of cell-salvaged blood. However, considering that the unconfirmed risk of spreading tumor cell is not a problem in the case of benign liver tumors, the use of cell saver should always be considered [15]. Furthermore, Schmidt A. et al. have demonstrated that cell-salvaged blood in liver resection seems to be safe for retransfusion with respect to cytokine release and complement activation [16].
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