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Giabicani M, Joly P, Sigaut S, Timsit C, Devauchelle P, Dondero F, Durand F, Froissant PA, Lamamri M, Payancé A, Restoux A, Roux O, Thibault-Sogorb T, Valainathan SR, Lesurtel M, Rautou PE, Weiss E. Predictive role of hepatic venous pressure gradient in bleeding events among patients with cirrhosis undergoing orthotopic liver transplantation. JHEP Rep 2024; 6:101051. [PMID: 38699073 PMCID: PMC11060951 DOI: 10.1016/j.jhepr.2024.101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Background & Aims Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes. The proportion of this risk related to portal hypertension is unclear. Hepatic venous pressure gradient (HVPG) is the gold standard for estimating portal hypertension. The aim of this study was to analyze the ability of HVPG to predict intraoperative major bleeding events during OLT in patients with cirrhosis. Methods We retrospectively analyzed a prospective database including all patients with cirrhosis who underwent OLT between 2010 and 2020 and had liver and right heart catheterizations as part of their pre-transplant assessment. The primary endpoint was the occurrence of an intraoperative major bleeding event. Results The 468 included patients had a median HVPG of 17 mmHg [interquartile range, 13-22] and a median MELD on the day of OLT of 16 [11-24]. Intraoperative red blood cell transfusion was required in 72% of the patients (median 2 units transfused), with a median blood loss of 1,000 ml [575-1,500]. Major intraoperative bleeding occurred in 156 patients (33%) and was associated with HVPG, preoperative hemoglobin level, severity of cirrhosis at the time of OLT (MELD score, ascites, encephalopathy), hemostasis impairment (thrombocytopenia, lower fibrinogen levels), and complications of cirrhosis (sepsis, acute-on-chronic liver failure). By multivariable regression analysis with backward elimination, HVPG, preoperative hemoglobin level, MELD score, and tranexamic acid infusion were associated with the primary endpoint. Three categories of patients were identified according to HVPG: low-risk (HVPG <16 mmHg), high-risk (HVGP ≥16 mmHg), and very high-risk (HVPG ≥20 mmHg). Conclusions HVPG predicted major bleeding events in patients with cirrhosis undergoing OLT. Including HVPG as part of pre-transplant assessment might enable better anticipation of the intraoperative course. Impact and implications Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes but the proportion of this risk related to portal hypertension is unclear. Our work shows that hepatic venous pressure gradient (HVPG), the gold standard for estimating portal hypertension, is a strong predictor of major bleeding events and blood loss volume in patients with cirrhosis undergoing OLT. Three groups of patients can be identified according to their risk of major bleeding events: low-risk patients with HVPG <16 mmHg, high-risk patients with HVPG ≥16 mmHg, and very high-risk patients with HVPG ≥20 mmHg. HVPG could be systematically included in the pre-transplant assessment to anticipate intraoperative course and tailor patient management.
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Affiliation(s)
- Mikhael Giabicani
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Paris, France
| | - Pauline Joly
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Stéphanie Sigaut
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Clara Timsit
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Pauline Devauchelle
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Fédérica Dondero
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - François Durand
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | | | - Myriam Lamamri
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Audrey Payancé
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Aymeric Restoux
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Olivier Roux
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Shantha Ram Valainathan
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Mickaël Lesurtel
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Emmanuel Weiss
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
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Gaspari R, Spinazzola G, Aceto P, Avolio AW, Delli Compagni M, Postorino S, Michi T, Fachechi DC, Modoni A, Antonelli M. Intensive Care Unit-Acquired Weakness after Liver Transplantation: Analysis of Seven Cases and a Literature Review. J Clin Med 2023; 12:7529. [PMID: 38137598 PMCID: PMC10743957 DOI: 10.3390/jcm12247529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.
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Affiliation(s)
- Rita Gaspari
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Paola Aceto
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy;
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Manuel Delli Compagni
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Stefania Postorino
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Teresa Michi
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Daniele Cosimo Fachechi
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Anna Modoni
- Department of Geriatric, Neurologic, Orthopedics and Head-Neck Science, Area of Neuroscience, Institute of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Massimo Antonelli
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
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3
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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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4
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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5
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Carrier FM, Deshêtres A, Ferreira Guerra S, Rioux-Massé B, Zaouter C, Lee N, Amzallag É, Joosten A, Massicotte L, Chassé M. Preoperative Fibrinogen Level and Bleeding in Liver Transplantation for End-stage Liver Disease: A Cohort Study. Transplantation 2023; 107:693-702. [PMID: 36150121 DOI: 10.1097/tp.0000000000004333] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver transplantation is a high-risk surgery associated with important perioperative bleeding and transfusion needs. Uncertainties remain on the association between preoperative fibrinogen level and bleeding in this population. METHODS We conducted a cohort study that included all consecutive adult patients undergoing a liver transplantation for end-stage liver disease in 1 center. We analyzed the association between the preoperative fibrinogen level and bleeding-related outcomes. Our primary outcome was intraoperative blood loss, and our secondary outcomes were estimated perioperative blood loss, intraoperative and perioperative red blood cell transfusions, reinterventions for bleeding and 1-y graft and patient survival. We estimated linear regression models and marginal risk models adjusted for all important potential confounders. We used restricted cubic splines to explore potential nonlinear associations and reported dose-response curves. RESULTS We included 613 patients. We observed that a lower fibrinogen level was associated with a higher intraoperative blood loss, a higher estimated perioperative blood loss and a higher risk of intraoperative and perioperative red blood cell transfusions (nonlinear effects). Based on an exploratory analysis of the dose-response curves, these effects were observed below a threshold value of 3 g/L for these outcomes. We did not observe any association between preoperative fibrinogen level and reinterventions, 1-y graft survival or 1-y patient survival. CONCLUSIONS This study suggests that a lower fibrinogen level is associated with bleeding in liver transplantation. The present results may help improving the selection of patients for further studies on preoperative fibrinogen administration in liver transplant recipients with end-stage liver disease.
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Affiliation(s)
- François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Annie Deshêtres
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Steve Ferreira Guerra
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | - Benjamin Rioux-Massé
- Department of Medicine, Hematology Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
| | - Cédrick Zaouter
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Nick Lee
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Éva Amzallag
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Bicêtre and Paul Brousse Hospitals, Assistance Publique Hôpitaux de Paris, Villejuif, France
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Michaël Chassé
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
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6
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Sanahuja JM, Reverter E, Ruiz Á, Saenz D, Martínez-Ocón J, Vidal J, Jiménez N, Colmenero J, García-Pagan JC, Fondevila C, Garcia-Valdecasas JC, Beltran J, Blasi A. Portal hypertension has no role in perioperative bleeding during liver transplantation with systematic porto-caval shunt. HPB (Oxford) 2023; 25:454-462. [PMID: 36759304 DOI: 10.1016/j.hpb.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND More than a half of patients undergoing liver transplantation (LT) receive intraoperative transfusion. Portal hypertension (PHT) may contribute to perioperative blood loss. We study the relationship between preoperative hepatic venous pressure gradient (HVPG) values and intraoperative transfusion requirements in adult patients undergoing LT. METHODS 160 cirrhotic patients undergoing first elective LT (2009-2019) with an HVPG measurement within the previous 6 months were included. Surgical technique was piggyback with portocaval shunt (PCS). The association of HVPG and other variables with transfusion requirements and blood loss were studied. RESULTS Blood loss (ml/kg) was positively correlated with HVPG, among other variables, but at multivariable analysis it only remained associated with MELD-Na and HCC indication. Regarding RBC transfusion, MELD-Na and hemoglobin were independently associated with the need and magnitude of RBC transfusion. Subanalysis by surgical stage (hepatectomy, anhepatic, neohepatic) and by serial HVPG cut-offs found no clear associations with either bleeding or transfusion. DISCUSSION The severity of PHT plays a minor role on bleeding and transfusion during LT in a contemporary cohort with systematic PCS. Main determinants of transfusion are liver function and baseline hemoglobin, which would seem the suitable goal to optimize transfusion in LT.
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Affiliation(s)
- Josep M Sanahuja
- Anaesthesiology Department. Hospital Clínic de Barcelona, IDIBAPS (Institut D'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Spain
| | - Enric Reverter
- Liver Unit, Hospital Clínic de Barcelona, IDIBAPS and CIBERehd (Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas), Spain
| | - Ángel Ruiz
- Donation and Transplant Procurement Unit, Hospital Clínic de Barcelona, Spain
| | - Denise Saenz
- Anaesthesiology Department. Hospital Clínic de Barcelona, IDIBAPS (Institut D'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Spain
| | - Julia Martínez-Ocón
- Anaesthesiology Department. Hospital Clínic de Barcelona, IDIBAPS (Institut D'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Spain
| | - Julia Vidal
- Anaesthesiology Department. Hospital Clínic de Barcelona, IDIBAPS (Institut D'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Spain
| | - Natalia Jiménez
- Liver Unit, Hospital Clínic de Barcelona, IDIBAPS and CIBERehd (Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas), Spain
| | - Jordi Colmenero
- Liver Unit, Hospital Clínic de Barcelona, IDIBAPS and CIBERehd (Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas), Spain
| | - Joan C García-Pagan
- Liver Unit, Hospital Clínic de Barcelona, IDIBAPS and CIBERehd (Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas), Spain
| | - Constantino Fondevila
- Department of General and Digestive Surgery, Hospital Universitario La Paz and IDIPAZ, CIBERehd, Madrid, Spain
| | - Juan C Garcia-Valdecasas
- Hepatobiliary and Pancreatic Surgery Department, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
| | - Joan Beltran
- Anaesthesiology Department. Hospital Clínic de Barcelona, IDIBAPS (Institut D'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Spain
| | - Annabel Blasi
- Anaesthesiology Department. Hospital Clínic de Barcelona, IDIBAPS (Institut D'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Spain.
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7
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DeSimone RA, Hess AS, Rajendran P, Tanaka KA, Cushing MM, Eichbaum Q. Blood utilization in liver transplantation (BUILT): A multidisciplinary survey of transfusion practices. Transfusion 2023; 63:83-91. [PMID: 36377099 DOI: 10.1111/trf.17180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to survey liver transplant centers in the United States to assess baseline practices in blood utilization and identify opportunities for standardization to optimize blood use in these complex cases. STUDY DESIGN AND METHODS Two surveys, one for transfusion medicine physicians and the other for anesthesiologists, were distributed to high-volume liver transplant centers. RESULTS The response rate was 52% for both surveys. The majority of respondents (90%) indicated they issue a standardized number of blood products to start surgeries. The most common number of products issued before the start of cases were 10 red blood cells (RBC) and 10 plasma units with no platelets or cryoprecipitate. On average, fewer RBC (7.5) and plasma (7) units were transfused than issued. Decisions to transfuse RhD+ RBCs to RhD- patients and use antigen untested units in alloimmunized patients were mainly handled on a case-by-case basis. Many centers reported utilizing viscoelastic testing (97%) and cell salvage (97%). Most centers reported standardized, laboratory-based intraoperative transfusion goals for RBCs (65%) and fibrinogen replacement (52%) but lacked a standardized approach for plasma (55%) and platelets (58%). DISCUSSION More blood products are issued during surgery than are transfused. Responses from anesthesiology providers suggest a broad consensus on practice. Almost all respondents use viscoelastic testing in the management of intraoperative coagulopathy, either alone or in combination with classical coagulation tests. The majority of programs do not transfuse clotting factor concentrates, including fibrinogen concentrate, prothrombin complex concentrates, and recombinant activated FVII, and do not use antifibrinolytics prophylactically.
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Affiliation(s)
- Robert A DeSimone
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York, USA
| | - Aaron S Hess
- Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Pranesh Rajendran
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York, USA
| | - Quentin Eichbaum
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Validation of 5 models predicting transfusion, bleeding, and mortality in liver transplantation: an observational cohort study. HPB (Oxford) 2022; 24:1305-1315. [PMID: 35131142 DOI: 10.1016/j.hpb.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 12/08/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Historically, orthotopic liver transplantation (OLT) has been associated with massive blood loss, blood transfusion and morbidity. In order to predict such outcomes five nomograms have been published relating to transfusions and morbidity associated with OLTs. These nomograms, developed on the basis of three cohorts of patients consisting of 406, 750, and 800 having undergone OLTs, aimed to predict a transfusion of ≥1 red blood cell unit (RBC), a transfusion of >2 RBC units, a blood loss of >900 ml, as well as one-month and one-year survival rates. The aim of this study was to validate these five nomograms in a contemporary, independent cohort of patients. METHODS Five nomograms were previously developed based on 406, 750, and 800 OLTs. In this study we performed a temporal validation of these nomograms on contemporary patients that consisted of three cohorts of 800, 250, and 200 OLTs. Logistic regression coefficients from the historic development cohorts were applied to the three contemporary temporal validation cohorts. RESULTS The most accurate nomogram was able to predict transfusion of ≥1 RBC units with an area under the curve (AUC) was 0.91. The second-best nomogram was able to predict bleeding of >900 ml with an AUC of 0.70. T he AUC of the third nomogram (transfusion of >2 RBC units) was 0.70. However, is temporal validation was suboptimal, due to a low prevalence of OLTs transfused with >2 RBC units. The last 2 nomograms exhibited clearly suboptimal AUC values of 0.54 and 0.61. CONCLUSION Two of the five nomograms predict blood transfusion and blood loss with excellent accuracy. Transfusion of ≥1 RBC unit and blood loss of >900 ml can be predicted on the basis of these nomograms. However, these nomograms are not accurate to predict one-month and one-year survival rates. These results should be further cross-validated, ideally prospectively, in additional external independent cohorts.
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9
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Shettar SS, Vandyck K, Tanaka KA. Coagulation Management in End-Stage Liver Disease. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Carrier FM, Ferreira Guerra S, Coulombe J, Amzallag É, Massicotte L, Chassé M, Trottier H. Intraoperative phlebotomies and bleeding in liver transplantation: a historical cohort study and causal analysis. Can J Anaesth 2022; 69:438-447. [PMID: 35112303 DOI: 10.1007/s12630-022-02197-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/31/2021] [Accepted: 11/03/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Liver transplantation is associated with major bleeding and red blood cell (RBC) transfusions. No well-designed causal analysis on interventions used to reduce transfusions, such as an intraoperative phlebotomy, has been conducted in this population. METHODS We conducted a historical cohort study among liver transplantations performed from July 2008 to January 2021 in a Canadian centre. The exposure was intraoperative phlebotomy. The outcomes were blood loss, perioperative RBC transfusions (intraoperative and up to 48 hr after surgery), intraoperative RBC transfusions, and one-year survival. We estimated marginal multiplicative factors (MFs), risk differences (RDs), and hazard ratios by inverse probability of treatment weighting both among treated patients and the whole population. Estimates are reported with 95% confidence intervals (CIs). RESULTS We included 679 patients undergoing liver transplantations of which 365 (54%) received an intraoperative phlebotomy. A phlebotomy did not reduce bleeding, transfusion risks, or mortality when estimated among the treated but reduced bleeding and transfusion risks when estimated among the whole population (MF, 0.85; 95% CI, 0.72 to 0.99; perioperative RD, -15.2%; 95% CI, -26.1 to -0.8; intraoperative RD, -14.7%; 95% CI, -23.2 to -2.8). In a subgroup analysis on 584 patients with end-stage liver disease, slightly larger effects were observed on both transfusion risks when estimated among the whole population while beneficial effects were observed on the intraoperative transfusion risk when estimated among the treated population. CONCLUSION The use of intraoperative phlebotomy was not consistently associated with better outcomes in all targets of inference but may improve outcomes among the whole population. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT04826666); registered 1 April 2021.
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Affiliation(s)
- François Martin Carrier
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montréal, QC, Canada. .,Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada. .,Critical Care Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Steve Ferreira Guerra
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
| | - Janie Coulombe
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
| | - Éva Amzallag
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montréal, QC, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Michaël Chassé
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montréal, QC, Canada.,Critical Care Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Helen Trottier
- Department of Social and Preventive Medicine, Université de Montréal, Sainte-Justine University Hospital Center, Montréal, QC, Canada
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11
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Jarry S, Halley I, Calderone A, Momeni M, Deschamps A, Richebé P, Beaubien-Souligny W, Denault A, Couture EJ. Impact of Processed Electroencephalography in Cardiac Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2022; 36:3517-3525. [PMID: 35618594 DOI: 10.1053/j.jvca.2022.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of brain function monitoring with processed electroencephalography (pEEG) during cardiac surgery is gaining interest for the optimization of hypnotic agent delivery during the maintenance of anesthesia. The authors sought to determine whether the routine use of pEEG-guided anesthesia is associated with a reduction of hemodynamic instability during cardiopulmonary bypass (CPB) separation and subsequently reduces vasoactive and inotropic requirements in the intensive care unit. DESIGN This is a retrospective cohort study based on an existing database. SETTING A single cardiac surgical center. PARTICIPANTS Three hundred patients undergoing cardiac surgery, under CPB, between December 2013 and March 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred and fifty patients had pEEG-guided anesthesia, and 150 patients did not have a pEEG-guided anesthesia. Multiple logistic regression demonstrated that pEEG-guided anesthesia was not associated with a successful CPB separation (p = 0.12). However, the use of pEEG-guided anesthesia reduced by 57% the odds of being in a higher category for vasoactive inotropic score compared to patients without pEEG (odds ratio = 0.43; 95% confidence interval: 0.26-0.73; p = 0.002). Duration of mechanical ventilation, fluid balance, and blood losses were also reduced in the pEEG anesthesia-guided group (p < 0.003), but there were no differences in organ dysfunction duration and mortality. CONCLUSION During cardiac surgery, pEEG-guided anesthesia allowed a reduction in the use of inotropic or vasoactive agents at arrival in the intensive care unit. However, it did not facilitate weaning from CPB compared to a group where pEEG was unavailable. A pEEG-guided anesthetic management could promote early vasopressor weaning after cardiac surgery.
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Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Isabelle Halley
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UC Louvain, Institut de Recherche Expérimentale et Clinique, Brussels, Belgium
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Île de Montréal, Université de Montréal, Montreal, Canada
| | | | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada; Department of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Canada
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12
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Association of Phlebotomy on Blood Product Transfusion Requirements During Liver Transplantation: An Observational Cohort Study on 1000 Cases. Transplant Direct 2022; 8:e1258. [PMID: 35372673 PMCID: PMC8963830 DOI: 10.1097/txd.0000000000001258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 12/22/2022] Open
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13
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Schneider T, Jackups R. Transfusion Medicine Informatics: A Review of Current Practice and a Glimpse into the Future. Clin Lab Med 2021; 41:713-725. [PMID: 34689975 DOI: 10.1016/j.cll.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Clinical informatics has been described as the "relentless pursuit of assisting people" by using data and information technology to improve health care. A core principle is that a person supported by information technology is superior to either a person or machine alone. Striving toward this harmonization, the transfusion medicine field has had a significant number of accomplishments. Clinical informatics interventions have helped achieve better quality, efficiency, and safety in nearly all aspects of transfusion medicine. This review summarizes these accomplishments and provides a preview of novel ideas that could transform transfusion medicine into a proactive, data-driven, and patient-centered discipline.
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Affiliation(s)
- Thomas Schneider
- Department of Pathology and Immunology, Washington University School of Medicine in Saint Louis, 660. S Euclid Avenue #8118, St. Louis, MO 63110, USA
| | - Ronald Jackups
- Department of Pathology and Immunology, Washington University School of Medicine in Saint Louis, 660. S Euclid Avenue #8118, St. Louis, MO 63110, USA.
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14
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Viguera L, Blasi A, Reverter E, Arjona B, Caballero M, Chocron I, García-López JA, Gutierrez R, Martin MJ, Pérez-Peña J, Pitera J, Zarragoikoetxea I, Sabaté A. Baseline haemoglobin and thromboelastometry are predictive of red blood cell requirements and one-year mortality in liver transplantation. Transfus Apher Sci 2021; 60:103259. [PMID: 34462218 DOI: 10.1016/j.transci.2021.103259] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND To determine the predictive capacity of baseline haemoglobin and maxim clot firmness (MCF) EXTEM thromboelastometry for intraoperative red blood cell (RBC) requirements and its influence on mortality. METHODS 591 adult liver transplant (LT) recipients from ten Spanish centres were reviewed. The main outcomes were the percentage of patients who received RBC and massive transfusion (≥ 6 RBC units), RBC units transfused, and mortality. RESULTS 76 % received a donor after brain death graft and 24 % a controlled donor after circulatory death graft. Median (interquartile ranges) RBC transfusion was 2 (0-4) units, and 63 % of patients were transfused. Comparing transfused and non-transfused patients, mean (standard deviation) for baseline haemoglobin was 10.4 (2.1) vs. 13.0 (1.9) g/dl (p = 0.001), EXTEM MCF was 51(11) vs. 55(9) mm (p = 0.001). Haemoglobin and EXTEM MCF were inversely associated with the need of transfusion odds ratio (OR) of 0.558 (95 % CI 0.497-0.627, p < 0.001) and OR 0.966 (95 % CI0.945-0.987, p = 0.002), respectively. Pre-operative baseline haemoglobin ≤ 10 g/dL predicted RBC transfusion, sensitivity of 93 % and specificity of 47 %. Massive transfusion (MT) was received by 19 % of patients. Haemoglobin ≤10 g/dL predicted MT with sensitivity 73 % and specificity of 52 %. One-year patient and graft survival were significantly lower in patients who required MT (78 % and 76 %, respectively) vs. those who did not (94 % and 93 %, respectively). DISCUSSION whereas EXTEM MCF is less dreterminant predicting RBC requirements, efforts are required to improve preoperative haemoglobin up to 10 g/dl in patients awaiting LT.
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Affiliation(s)
- Laura Viguera
- Anaesthesia Department, Hospital Universitari Bellvitge, Spain
| | - Annabel Blasi
- Anaesthesia Department, Hospital Clinic de Barcelona, IDIBAPS, Spain.
| | | | | | - Marta Caballero
- Anaesthesia Department, Hospital Universitari Bellvitge, Spain
| | | | | | | | - Maria Jesús Martin
- Anaesthesia Department, Complejo Hospitalario Universitario A Coruña, Spain
| | - Jose Pérez-Peña
- Anaesthesia Department, Hospital Universitario Gregorio Marañón de Madrid, Spain
| | - Javier Pitera
- Anaesthesia Department, Hospital Universitario de Badajoz, Spain
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15
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Martinez S, Garcia I, Ruiz A, Tàssies D, Reverter JC, Colmenero J, Beltran J, Fondevila C, Blasi A. Is antivitamin K reversal required in patients with cirrhosis undergoing liver transplantation? Transfusion 2021; 61:3008-3016. [PMID: 34358342 DOI: 10.1111/trf.16607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 06/13/2021] [Accepted: 07/05/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antivitamin K agent (AVK) reversal in patients with cirrhosis awaiting liver transplantation (LT) is not defined in guidelines. We investigated the effect of reversion with prothrombin complex concentrate (PCC) on intraoperative transfusion, bleeding, and safety in LT patients on AVK. STUDY DESIGN AND METHODS In 511 patients undergoing LT, we identified 25 patients treated with AVK (AVK group) and 13 patients with incidental portal vein thrombosis (PVT) without AVK (incidental PVT group). Fifty patients who underwent LT without PVT or AVK matched by age, model for end stage of liver disease (MELD), body mass index (BMI), and cirrhosis etiology were selected as the control group. RESULTS There were no significant differences between the three groups in intraoperative blood loss, transfusion, and postoperative bleeding. In the AVK group, there were no differences between patients who received PCC and those who did not in intraoperative blood loss, red blood cells, fibrinogen, and platelet transfusion, or postoperative bleeding. PCC use had no effect on RBC transfusion in patients who had international normalized ratio or clotting time above versus below median values of the two parameters at baseline (2.3 and 103 s, respectively). No thrombotic events were detected in patients who received PCC. DISCUSSION These data suggest that systematic administration of PCC to revert AVK prior to LT should be reconsidered.
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Affiliation(s)
- Samira Martinez
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Isabel Garcia
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Angel Ruiz
- Donation and Transplantation Coordination Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Dolors Tàssies
- Hemostasis Department, IDIBAPS, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Jordi Colmenero
- Hepatology Department, Hospital Clinic Barcelona IDIBAPS, Barcelona, Spain
| | - Joan Beltran
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
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16
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Shaylor R, Desmond F, Lee DK, Koshy AN, Hui V, Tang GT, Fink M, Weinberg L. The Impact of Intraoperative Donor Blood on Packed Red Blood Cell Transfusion During Deceased Donor Liver Transplantation: A Retrospective Cohort Study. Transplantation 2021; 105:1556-1563. [PMID: 33464032 PMCID: PMC8221718 DOI: 10.1097/tp.0000000000003395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/05/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blood from deceased organ donors, also known as donor blood (DB), has the potential to reduce the need for packed red blood cells (PRBCs) during liver transplantation (LT). We hypothesized that DB removed during organ procurement is a viable resource that could reduce the need for PRBCs during LT. METHODS We retrospectively examined data on LT recipients aged over 18 y who underwent a deceased donor LT. The primary aim was to compare the incidence of PRBC transfusion in LT patients who received intraoperative DB (the DB group) to those who did not (the nondonor blood [NDB] group). RESULTS After a propensity score matching process, 175 patients received DB and 175 did not. The median (first-third quartile) volume of DB transfused was 690.0 mL (500.0-900.0), equivalent to a median of 3.1 units (2.3-4.1). More patients in the NDB group received an intraoperative PRBC transfusion than in the DB group: 74.3% (95% confidence intervals, 67.8-80.8) compared with 60% (95% confidence intervals, 52.7-67.3); P = 0.004. The median number of PRBCs transfused intraoperatively was higher in the NDB group compared with the DB group: 3 units (0-6) compared with 2 units (0-4); P = 0.004. There were no significant differences observed in the secondary outcomes. CONCLUSIONS Use of DB removed during organ procurement and reinfused to the recipient is a viable resource for reducing the requirements for PRBCs during LT. Use of DB minimizes the exposure of the recipient to multiple donor sources.
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Affiliation(s)
- Ruth Shaylor
- Department of Anesthesia, Austin Health, Heidelberg, VIC, Australia
| | - Fiona Desmond
- Department of Anesthesia, Austin Health, Heidelberg, VIC, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | | | - Victor Hui
- Department of Anesthesia, Austin Health, Heidelberg, VIC, Australia
| | - Gia Toan Tang
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
| | - Michael Fink
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, VIC, Australia
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
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Blasi A, Cardenas A. Invasive Procedures in Patients with Cirrhosis: A Clinical Approach Based on Current Evidence. Clin Liver Dis 2021; 25:461-470. [PMID: 33838861 DOI: 10.1016/j.cld.2021.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aim on of this article is to provide an update on the coagulation disturbances of patients with cirrhosis. It summarizes basic concepts of coagulation in cirrhosis, available tests used to predict bleeding, procedures and risk of bleeding, and the rationale and expert-based recommendations of prophylactic measures for patients with cirrhosis who undergo invasive procedures.
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Affiliation(s)
- Annabel Blasi
- Anesthesia Department, Hospital Clinic of Barcelona, Villarroel 170, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain; GI/Liver Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain; Department of Medicine, University of Barcelona, Spain.
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18
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Park B, Yoon J, Kim HJ, Jung YK, Lee KG, Choi D. Transfusion Status in Liver and Kidney Transplantation Recipients-Results from Nationwide Claims Database. J Clin Med 2020; 9:E3613. [PMID: 33182639 PMCID: PMC7697733 DOI: 10.3390/jcm9113613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study analyzed the status and trends of transfusion and its associated factors among liver and kidney transplantation recipients. METHODS A total of 10,858 and 16,191 naïve liver or kidney transplantation recipients from 2008 to 2017 were identified through the National Health Insurance Service database. The prescription code for transfusion and the presence, number, and amount of each type of transfusion were noted. The odds ratios and 95% confidence intervals were determined to identify significant differences in transfusion and blood components by liver and kidney transplantation recipient characteristics. RESULTS In this study, 96.4% of liver recipients and 59.7% of kidney recipients received transfusions related to the transplantation operation, mostly platelet and fresh frozen plasma. Higher perioperative transfusion in women and declining transfusion rates from 2008 to 2017 were observed in both liver and kidney recipients. In liver recipients, the transfusion rate in those who received organs from deceased donors was much higher than that in those who received organs from living donors; however, the mortality rate according to transfusion was higher only in recipients of deceased donor organs. In kidney recipients, a higher mortality rate was observed in those receiving transfusion than that in patients without transfusion. CONCLUSIONS In Korea, the transfusion rates in liver and kidney recipients were relatively higher than those in other countries. Sociodemographic factors, especially sex and year of transplantation, were associated with transfusion in solid organ recipients, possibly as surrogates for other causal clinical factors.
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Affiliation(s)
- Boyoung Park
- Department of Medicine, College of Medicine, Hanyang University, Seoul 04763, Korea;
| | - Junghyun Yoon
- Graduate School of Public Health, Hanyang University, Seoul 04763, Korea;
| | - Han Joon Kim
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
| | - Yun Kyung Jung
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
- Hanyang ICT Fusion Medical Research Center, Seoul 04763, Korea
| | - Kyeong Geun Lee
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
| | - Dongho Choi
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
- Hanyang ICT Fusion Medical Research Center, Seoul 04763, Korea
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19
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Effects of Intraoperative Fluid Balance During Liver Transplantation on Postoperative Acute Kidney Injury: An Observational Cohort Study. Transplantation 2020; 104:1419-1428. [PMID: 31644490 DOI: 10.1097/tp.0000000000002998] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. METHODS We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. RESULTS We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). CONCLUSIONS We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.
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Rengeiné TK, Tihanyi E, Dinya E, Smudla A, Kóbori L, Kanizsai P, Fazakas J. Mapping nursing interventions using the Therapeutic Intervention Scoring System in bloodless liver transplantations. Intensive Crit Care Nurs 2020; 61:102917. [PMID: 32855007 DOI: 10.1016/j.iccn.2020.102917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Accepted: 07/01/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Simplified Therapeutic Intervention Scoring System adapted to liver transplantation by King's College Hospital rank 138 activities to determine the nursing workload, diagnostic, monitoring and therapeutic needs. OBJECTIVES To evaluate nursing activities of "King's-TISS" score grouped in organ systems and nurse patient ratio in the perioperative 48 hours of blood product free liver transplantations (LT). METHODS The "King's-TISS" score's were analysed by nursing procedures and grouped, scored according to organ systems. The nursing workloads were studied during LT (T1), on arrival on the ICU (T2) and 12-24-48 hours after LT (T3-T4-T5). RESULTS The total of "King's-TISS" score points were decreased by ≥20% daily (p = 0.001). The mean score of 104 ± 3.5 points (CI:104-105) during LT decreased to 84.7 ± 12 points (CI:83-86) in 48 hours (T5). The "metabolic" and "haemostasis" points increased (p = ).01), the "immunology" points unchanged (T2-T5) postoperatively. A slight decrease was observed in case of "basic nursing care", "monitoring", "neurologic support", "renal support" and "cardiovascular support" points (T2-T5, p < .01). The "invasive intervention" and "ventilatory support" points strongly decreased (T2-T5, p < .001). One "King's-TISS" point was found to equal 7.4 minutes with a nurse patient ratio of 2:1 intraoperatively and 1:1 postoperatively. CONCLUSION Absence of blood product administration in LT decreases the total and organ specific workload, except the metabolic, haemostasis, immunology and basic support requirement. It was not within the scope of the King's-TISS score to analyse the application of viscoelastic haemostasis test and coagulation factor concentrate administration.
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Affiliation(s)
- T K Rengeiné
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
| | - E Tihanyi
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - E Dinya
- Semmmelweis University, Institute of Digital Health Sciences, Budapest, Hungary.
| | - A Smudla
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - L Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - P Kanizsai
- University of Pécs, Clinical Centre, University Department of Emergency Medicine, Pécs, Hungary; Semmelweis University, Faculty of Medicine, Department of Anesthesiology and Intensive Therapy, Hungary.
| | - J Fazakas
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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21
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Effects of intraoperative hemodynamic management on postoperative acute kidney injury in liver transplantation: An observational cohort study. PLoS One 2020; 15:e0237503. [PMID: 32810154 PMCID: PMC7446917 DOI: 10.1371/journal.pone.0237503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/23/2020] [Indexed: 12/28/2022] Open
Abstract
Background Intraoperative restrictive fluid management strategies might improve postoperative outcomes in liver transplantation. Effects of vasopressors within any hemodynamic management strategy are unclear. Methods We conducted an observational cohort study on adult liver transplant recipients between July 2008 and December 2017. We measured the effect of vasopressors infused at admission in the intensive care unit (ICU) and total intraoperative fluid balance. Our primary outcome was 48-hour acute kidney injury (AKI) and our secondary outcomes were 7-day AKI, need for postoperative renal replacement therapy (RRT), time to extubation in the ICU, time to ICU discharge and survival up to 1 year. We fitted models adjusted for confounders using generalized estimating equations or survival models using robust standard errors. We reported results with 95% confidence intervals. Results We included 532 patients. Vasopressors use was not associated with 48-hour or 7-day AKI but modified the effects of fluid balance on RRT and mortality. A higher fluid balance was associated with a higher need for RRT (OR = 1.52 [1.15, 2.01], p<0.001 for interaction) and lower survival (HR = 1.71 [1.26, 2.34], p<0.01 for interaction) only among patients without vasopressors. In patients with vasopressors, higher doses of vasopressors were associated with a higher mortality (HR = 1.29 [1.13, 1.49] per 10 μg/min of norepinephrine). Conclusion The presence of any vasopressor at the end of surgery was not associated with AKI or RRT. The use of vasopressors might modify the harmful association between fluid balance and other postoperative outcomes. The liberal use of vasopressors to implement a restrictive fluid management strategy deserves further investigation.
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22
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Rengeiné TK, Máthé Z, Piros L, Dinya E, Smudla A, Mándli T, Kóbori L, Doros A, Kanizsai P, Fazakas J. How Much Is the Inevitable Loss of Different Coagulation Factors During Blood Product-Free Liver Transplantations? Transplant Proc 2020; 52:2988-2995. [PMID: 32653159 DOI: 10.1016/j.transproceed.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bloodless liver transplantations (LT) have already been reported, but special characteristics of hemostatic changes remain less defined. The aim of this study was to evaluate the "inevitable" loss of coagulation factors (CF) in blood product-free LT. METHODS Blood product and CF concentrate-free LT patient data were analyzed in terms of the first 2 days of perioperative hemostasis kinetics (N = 59). CF levels (FI, II, V, VII, X, and XIII), platelet (PLT) levels, and hemoglobin levels were measured before LT (T1), on arrival at the intensive care unit (T2), and 12, 24, and 48 hours after LT (T3, T4, and T5, respectively). Thromboelastographic (TEG) parameters were determined before and at the end of LT (T1-T2). RESULTS Fibrinogen levels decreased by 1.2 ± 0.6 g/L, prothrombin levels by 26% ± 14%, factor V levels by 40% ± 23%, VII levels by 29% ± 19%, and X levels by 39% ± 22% (P < .001). From T2 to T4 fibrinogen increased by 0.9 ± 0.6g/L for 24 hours (P < .001). Factor II, V, and VII levels increased by 20% ± 16%, 31% ± 32%, and 12% ± 27%, respectively, between T3 and T5 (P < .001). However, factor X reached only half of the T1 level (T3-T5, P < .001). Platelet count increased in 34 (58%) patients at T2 (P < .001). The TEG parameters remained in the normal range during LT (T1-T2). CONCLUSION The major findings of this study advocate that "inevitable" levels of CF decrease during LT by an average of 1.2 g/L in terms of fibrinogen and 23% to 40% regarding factors II, V, VII, and X. The authors suggest that knowing the "magic numbers" and comparing them against baseline laboratory results might predict the possibility of blood product-free transplant, providing confidence and safety to the surgeon and the anesthetist.
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Affiliation(s)
- T K Rengeiné
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
| | - Z Máthé
- Department of Surgery, Division of Transplant Surgery, Medical University Graz, Graz, Austria
| | - L Piros
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - E Dinya
- Semmmelweis University, Institute of Digital Health Sciences, Budapest, Hungary
| | - A Smudla
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - T Mándli
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - L Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - A Doros
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - P Kanizsai
- Department of Emergency Medicine, University of Pécs, Clinical Centre, Pécs, Hungary
| | - J Fazakas
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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Mukhtar A, Lotfy A, Hussein A, Fouad E. Splanchnic and systemic circulation cross talks: Implications for hemodynamic management of liver transplant recipients. Best Pract Res Clin Anaesthesiol 2020; 34:109-118. [PMID: 32334781 DOI: 10.1016/j.bpa.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/11/2019] [Indexed: 12/21/2022]
Abstract
The interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In a patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from the systemic circulation into the splanchnic bed, which decreases the effective blood volume. Moreover, rapid volume loading in these patients has less impact on the cardiac output because a higher proportion of infused fluid is shifted to the splanchnic area. Thus, in dissection phase, the traditional approach of volume loading to maintain intraoperative hemodynamic stability not only seems ineffective, but it may also aggravate surgical bleeding. Two approaches of volume therapy have been mentioned to maintain hemodynamic stability during liver transplantation: splanchnic volume reduction by volume restriction with or without phlebotomy to maintain low central venous pressure (CVP), and splanchnic decongestion using splanchnic vasoconstrictors. After reperfusion, an increase in the central blood volume was thought to have a deleterious effect on the new graft function; however, the precise central venous pressure value that causes hepatic congestion after reperfusion is unknown.
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Affiliation(s)
- Ahmed Mukhtar
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Faculty of Medicine, Cairo University, 1 Alsaray st, Almanial, Cairo, Egypt.
| | - Ahmed Lotfy
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Faculty of Medicine, Cairo University, 1 Alsaray st, Almanial, Cairo, Egypt.
| | - Amr Hussein
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Faculty of Medicine, Cairo University, 1 Alsaray st, Almanial, Cairo, Egypt.
| | - Eman Fouad
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Faculty of Medicine, Cairo University, 1 Alsaray st, Almanial, Cairo, Egypt.
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Park L, Gilbert R, Baker L, Shorr R, Workneh A, Turcotte S, Bertens KA, Abou-Khalil J, Balaa FK, Martel G. The safety and efficacy of hypovolemic phlebotomy on blood loss and transfusion in liver surgery: a systematic review and meta-analysis. HPB (Oxford) 2020; 22:340-350. [PMID: 31734240 DOI: 10.1016/j.hpb.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7-10 mL/kg) without volume replacement. The subsequent central venous pressure (CVP) reduction is hypothesized to decrease blood loss and the need for blood transfusion. The objective was to conduct a systematic assessment of the safety and efficacy of HP on blood loss and transfusion in the liver surgery literature. METHODS MEDLINE, EMBASE, and Cochrane Library databases were searched. Outcomes of interest included blood loss, allogenic red blood cell transfusion, postoperative adverse events, and CVP change. A qualitative synthesis and meta-analysis were performed as appropriate. RESULTS Four cohort studies, one case series, and three randomized controlled trials involving 2255 patients were included. Meta-analysis of studies involving liver resections for any indication (n = 6) found no difference in transfusion (OR 0.38, p = 0.12) or incidence of adverse events with HP compared to non-use. Pooling of studies involving liver resections for an underlying pathology (n = 4) revealed HP was associated with significant reduction in transfusion (OR 0.25, p = 0.03) but no differences in blood loss (-173 mL, p = 0.17). CONCLUSION This review suggests HP is safe and associated with decreased transfusion in patients undergoing liver surgery. It supports further investigation.
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Affiliation(s)
- Lily Park
- Faculty of Medicine, University of Ottawa, Canada
| | - Richard Gilbert
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Laura Baker
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada
| | - Simon Turcotte
- Hepatopancreatobiliary and Liver Transplantation Division, Centre hospitalier de l'Université de Montréal, Canada
| | - Kimberley A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.
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25
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Restrictive fluid management strategies and outcomes in liver transplantation: a systematic review. Can J Anaesth 2019; 67:109-127. [PMID: 31556006 DOI: 10.1007/s12630-019-01480-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/12/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Restrictive fluid management strategies have been proposed to reduce complications in liver transplant recipients. We conducted a systematic review to evaluate the effects of restrictive perioperative fluid management strategies, compared with liberal ones, on postoperative outcomes in adult liver transplant recipients. Our primary outcome was acute kidney injury (AKI). Our secondary outcomes were bleeding, mortality, and other postoperative complications. SOURCE We searched major databases (CINAHL, EMB Reviews, EMBASE, MEDLINE, and the grey literature) from their inception to 10 July 2018 for randomized-controlled trials (RCTs) and observational studies comparing two fluid management strategies (or observational studies reporting two outcomes with available data on fluid volume received) in adult liver transplant recipients. Study selection, data abstraction, and risk of bias assessment were performed by at least two investigators. Data from RCTs were pooled using risk ratios (RR) and mean differences (MD) with random-effect models. PRINCIPAL FINDINGS We found seven RCTs and 29 observational studies. Based on RCTs, fluid management strategies did not have any effect on AKI, mortality, or any other postoperative complications. Intraoperative RCTs suggested that a restrictive fluid management strategy reduced pulmonary complications (RR, 0.69; 95% confidence interval [CI], 0.47 to 0.99; n = 283; I2 = 27%), duration of mechanical ventilation (MD, -13.04 hr; 95% CI, -22.2 to -3.88; n = 130; I2 = 0%) and blood loss (MD, -1.14 L; 95% CI, -1.72 to -0.57; n = 151; I2 = 0%). CONCLUSION Based on low or very low levels of evidence, we did not find any association between restrictive fluid management strategies and AKI, but we observed possible protective effects of intraoperative restrictive fluid management strategies on other outcomes. TRIAL REGISTRATION PROSPERO (CRD42017054970); registered 18 May, 2017.
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Danforth D, Gabriel RA, Clark AI, Newhouse B, Khoche S, Vig S, Sanchez R, Schmidt UH. Preoperative risk factors for massive transfusion, prolonged ventilation requirements, and mortality in patients undergoing liver transplantation. Korean J Anesthesiol 2019; 73:30-35. [PMID: 31378055 PMCID: PMC7000286 DOI: 10.4097/kja.19108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/30/2019] [Indexed: 01/21/2023] Open
Abstract
Background Despite improvements in techniques and management of liver transplant patients, numerous perioperative complications that contribute to perioperative mortality remain. Models to predict intraoperative massive blood transfusion, prolonged mechanical ventilation, or in-hospital mortality in liver transplant recipients have not been identified. In this study we aim to identify preoperative factors associated with the above mentioned complications. Methods A retrospective observational analysis was conducted on data collected from 124 orthotopic liver transplants performed at a single institution between 2014 and 2017. A multivariable logistic regression using backwards elimination was performed for three defined outcomes (massive transfusion ≥ 10 units packed red blood cells (PRBC), prolonged mechanical ventilation > 24 h, and in-hospital mortality) to identify associations with preoperative characteristics. Results Statistically significant (P < 0.05) associations with massive transfusion ≥ 10 units PRBC were hepatocellular carcinoma and preoperative transfusion of PRBC. Significant associations with prolonged mechanical ventilation > 24 h were hepatitis C, alcoholic hepatitis, elevated preoperative alanine aminotransferase, and hepatorenal syndrome. Male gender was protective for requiring prolonged mechanical ventilation. End-stage renal disease and hepatitis B were significantly associated with increased in-hospital mortality. Conclusions This study identified risk factors associated with common perioperative complications of liver transplantation. These factors may assist practitioners in risk stratification and may form the basis for further investigations of potential interventions to mitigate these risks.
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Affiliation(s)
- Dennis Danforth
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA.,Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA
| | - Anthony I Clark
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Beverly Newhouse
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Swapnil Khoche
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Sanjana Vig
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Ramon Sanchez
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Ulrich H Schmidt
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
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Smith NK, Zerillo J, Schlichting N, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2018. Semin Cardiothorac Vasc Anesth 2019; 23:188-204. [DOI: 10.1177/1089253219842655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A PubMed search revealed 1382 articles on pancreatic transplantation, 781 on intestinal transplantation, more than 7200 on kidney transplantation, and more than 5500 on liver transplantation published between January 1, 2018, and December 31, 2018. After narrowing the list down to human studies, 436 pancreatic, 302 intestinal, 1920 liver, and more than 2000 kidney transplantation studies were screened for inclusion in this review.
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Affiliation(s)
- Natalie K. Smith
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Jeron Zerillo
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | | | - Tetsuro Sakai
- University of Pittsburgh Medical Center Health System, PA, USA
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Lai Y, Crowley J, Dalia AA. Model for End-Stage Liver Disease Impact on Outcomes of Orthotopic Liver Transplantation Patients. J Cardiothorac Vasc Anesth 2019; 33:2726-2727. [PMID: 31076301 DOI: 10.1053/j.jvca.2019.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/26/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Yvonne Lai
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jerome Crowley
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA
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29
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Milan Z, Katyayani K, Cubas G, Unic‐Stojanovic D, Cooper M, Bras P, Macmillan J. Trends in transfusion practice over 20 years in paediatric liver transplant programme. Vox Sang 2019; 114:355-362. [DOI: 10.1111/vox.12771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 02/13/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022]
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30
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Massicotte L, Carrier FM, Karakiewicz P, Hevesi Z, Thibeault L, Nozza A, Bilodeau M, Roy A, Denault AY. Impact of MELD Score-Based Organ Allocation on Mortality, Bleeding, and Transfusion in Liver Transplantation: A Before-and-After Observational Cohort Study. J Cardiothorac Vasc Anesth 2019; 33:2719-2725. [PMID: 31072701 DOI: 10.1053/j.jvca.2019.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the effect of the Model for End-Stage Liver Disease (MELD)-based allocation system on mortality, bleeding, and transfusion requirement in orthotopic liver transplantation (OLT). DESIGN OLTs were studied for this observational study (before-and-after observational cohort study). SETTING One community hospital. PARTICIPANTS The study comprised 686 patients who underwent 750 consecutive OLTs. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Patients who underwent OLT in the MELD era had an adjusted lower 1-year mortality (adjusted odds ratio 0.45 [0.24-0.83]) compared with patients who underwent OLT the pre-MELD era. No significant difference in 1-month mortality was observed. Other variables with a significant effect on 1-year mortality in multivariate analysis were preoperative international normalized ratio, intraoperative use of a phlebotomy, total intraoperative volume of crystalloid infused, and retransplantation. Blood loss was greater in the MELD era (median difference 200 mL; p < 0.001), as were red blood cell, fresh frozen plasma, and cryoprecipitate transfusions. More patients in the MELD era received at least 1 transfusion (27% v 20%; p = 0.024). CONCLUSION The MELD allocation system did not affect 1-month mortality, but a decrease in 1-year mortality was demonstrated. Blood loss and transfusions increased during OLTs performed in the MELD era. The role of other variables should be explored further to explain postoperative morbidity and mortality.
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Affiliation(s)
- Luc Massicotte
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.
| | - François Martin Carrier
- Department of Anesthesiology and Department of Medicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada; Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Karakiewicz
- Department of Surgery, Urology Division, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Zoltan Hevesi
- Department of Anesthesiology, University of Wisconsin, Madison, WI, Wisconsin
| | - Lynda Thibeault
- Department of Social and Preventive Medicine, Public Health School, Université de Montréal, Montréal, Quebec, Canada
| | - Anna Nozza
- Montreal Health Innovation Coordinating Center, Montréal, Quebec, Canada
| | - Marc Bilodeau
- Department of Medicine, Liver Unit, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - André Roy
- Department of Surgery, Hepato-Biliary Division, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - André Y Denault
- Department of Anesthesiology and Department of Medicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada; Department of Anesthesiology, Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
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31
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Carrier FM, Chassé M, Wang HT, Aslanian P, Bilodeau M, Turgeon AF. Effects of perioperative fluid management on postoperative outcomes in liver transplantation: a systematic review protocol. Syst Rev 2018; 7:180. [PMID: 30382884 PMCID: PMC6211404 DOI: 10.1186/s13643-018-0841-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/12/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Liver transplant recipients suffer many complications, but few intraoperative interventions supported by high-quality evidence have been found effective to reduce their incidence or severity. Fluid balance has been proposed as an important aspect of perioperative care in high-risk recipients. We will conduct a systematic review aimed at evaluating the effects of restrictive perioperative fluid management strategies compared to liberal ones on clinically significant postoperative outcomes. METHODS We will search through major databases (CINAHL Complete, EMB Reviews, EMBASE, MEDLINE, PubMed, and the gray literature (CADTH, Clinical Trials, National Guideline Clearing House, NICE, MedNar, Google Scholar and Open Grey)), from inception up to a date close to the review submission for publication, for eligible studies. Randomized controlled trials and comparative non-randomized studies (prospective or retrospective) comparing two fluid management strategies (or two outcomes with available data on fluid volume received for observational studies) on adult liver recipients will be included. Eligible studies will have to report at least one postoperative complication or mortality. Our primary outcome will be acute renal failure and our secondary exploratory outcomes will be all other postoperative complications and mortality. Study selection and data abstraction using an electronic standardized form will be performed by three authors. Risk of bias will be evaluated and data will be pooled if limited clinical diversity is observed. DISCUSSION Human organs available for transplantation are scarce resources. Strategies to improve recipients' survival are needed. We hypothesize that restrictive fluid management strategies will be associated with better postoperative outcomes than liberal fluid management strategies. This systematic review will improve our understanding of the available evidence and help us better inform future clinical trials. SYSTEMATIC REVIEW REGISTRATION This systematic review protocol is registered in PROSPERO ( CRD42017054970 ).
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Affiliation(s)
- François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 4e étage, Pavillon D, porte D04-5028, Montréal, Québec, H2X 0C1, Canada. .,Department of Medicine - Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 10e étage, Pavillon D, porte D10-2143, Montréal, Québec, H2X 0C1, Canada. .,Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.
| | - Michaël Chassé
- Department of Medicine - Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 10e étage, Pavillon D, porte D10-2143, Montréal, Québec, H2X 0C1, Canada.,Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Han Ting Wang
- Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.,Department of Medicine - Critical Care Division, CIUSSS de l'Est-de-l'île-de-Montréal - Hôpital Maisonneuve-Rosemont, 5415 Boulevard de l'Assomption, Montréal, Québec, H1T 2M4, Canada
| | - Pierre Aslanian
- Department of Medicine - Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 10e étage, Pavillon D, porte D10-2143, Montréal, Québec, H2X 0C1, Canada
| | - Marc Bilodeau
- Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.,Liver Unit, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, 1000, rue St-Denis, Montréal, Québec, H2X 0C1, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Université Laval, 1401, 18e rue, Québec, Québec, G1J 1Z4, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Avenue de la Médecine, Québec, Québec, G1V 0A6, Canada
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