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Justo I, Marcacuzco A, Caso Ó, Manrique A, García-Sesma Á, García A, Rivas C, Jiménez-Romero C. Risk factors of massive blood transfusion in liver transplantation: consequences and a new index for prediction including the donor. Cir Esp 2023; 101:684-692. [PMID: 37739219 DOI: 10.1016/j.cireng.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/21/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Massive blood transfusion (MBT) is a common occurrence in liver transplant (LT) patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. Despite advances in surgical techniques, anesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. METHODS One thousand four hundred and sixty-nine LT were performed at our institution between May 2003 and December 2020, and data was available regarding transfusion for 1198 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 h posttransplant, and we analyzed the differences between the groups. RESULTS Out of the 1198 patients, 607 (50.7%) met criteria for MBT. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT to those that did not (92.6%, 85.2% and 79.7%, respectively, in the non MBT group, vs. 78.1%, 71.6% y 66.8%, respectively, in the MBT group). MBT was associated with a 1.5 mortality risk as opposed to non-MBT patients. Logistical regression analysis of our variables yielded the following results for a new model, including serum creatinine (OR 1.97), sodium (OR 1.73), hemoglobin (OR 1.99), platelets (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) and split liver donation. CONCLUSION Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative hemoglobin, INR and serum creatinine.
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Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "12 de Octubre" University Hospital, Spain.
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, "12 de Octubre" University Hospital, Spain
| | - Óscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, "12 de Octubre" University Hospital, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, "12 de Octubre" University Hospital, Spain
| | - Álvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, "12 de Octubre" University Hospital, Spain
| | - Adolfo García
- Department of Anestheiology, "12 de Octubre" University Hospital, Spain
| | - Cristina Rivas
- Service of Thoracic Surgery and Lung Transplantation, University Hospital Salamanca, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, "12 de Octubre" University Hospital, Spain
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Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, Palmer AJR. Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery. J Clin Epidemiol 2023; 159:10-30. [PMID: 37156342 DOI: 10.1016/j.jclinepi.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between January 1, 2000 and June 30, 2021. We extracted study characteristics, discrimination performance (c-statistics) of final models, and data, which we used to perform risk of bias assessment using the Prediction model risk of bias assessment tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
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Affiliation(s)
- Paula Dhiman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Jie Ma
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Victoria N Gibbs
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexandros Rampotas
- Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | - Hassan Kamal
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland DD1 9SY
| | - Sahar S Arshad
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | - Michael F Murphy
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE, UK
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Kloesel B, Kovatsis PG, Faraoni D, Young V, Kim HB, Vakili K, Goobie SM. Incidence and predictors of massive bleeding in children undergoing liver transplantation: A single-center retrospective analysis. Paediatr Anaesth 2017; 27:718-725. [PMID: 28557286 DOI: 10.1111/pan.13162] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation represents a major surgery involving a highly vascular organ. Reports defining the scope of bleeding in pediatric liver transplants are few. AIMS We conducted a retrospective analysis of liver transplants performed at our pediatric tertiary care center to quantify blood loss, blood product utilization, and to determine predictors for massive intraoperative bleeding. METHODS Pediatric patients who underwent isolated liver transplantation at Boston Children's Hospital between 2011 and 2016 were included. The amount of blood product transfused in the perioperative period and the incidence of postoperative complications were reported. Univariable and multivariable logistic regressions were used to determine predictors for massive bleeding, defined as estimated blood loss exceeding one circulating blood volume within 24 hours. RESULTS Sixty-eight children underwent liver transplantation during the study period and were included in the analysis. Multivariable logistic regression analysis identified the following independent predictors of massive bleeding: preoperative hemoglobin level <8.5 g/dL (OR 11.09, 95% CI 1.87-65.76), INR >1.5 (OR 11.62, 95% CI 2.36-57.26), platelet count <100 109 /L (OR 7.92, 95% CI 1.46-43.05), and surgery duration >600 minutes (OR 6.97, 95% CI 0.99-48.92). CONCLUSIONS Pediatric liver transplantation is associated with substantial blood loss and a significant blood product transfusion burden. A 43% incidence of massive bleeding is reported. Further efforts are needed to improve bleeding management in this high-risk population.
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Affiliation(s)
- Benjamin Kloesel
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Transplant Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Vanessa Young
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Heung Bae Kim
- Pediatric Transplant Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Khashayar Vakili
- Pediatric Transplant Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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