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Kahn RM, Boerner T, Kim M, Lam C, Gordhandas S, Yeoshoua E, Zhou QC, Iasonos A, Al-Niaimi A, Gardner GJ, Long Roche K, Sonoda Y, Zivanovic O, Grisham RN, Abu-Rustum NR, Chi DS. A pre-operative scoring model to estimate the risk of blood transfusion over an ovarian cancer debulking surgery (BLOODS score): a Memorial Sloan Kettering Cancer Center Team Ovary study. Int J Gynecol Cancer 2024; 34:1051-1059. [PMID: 38950927 PMCID: PMC11237961 DOI: 10.1136/ijgc-2024-005660] [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] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVES To develop a pre-operative tool to estimate the risk of peri-operative packed red blood cell transfusion in primary debulking surgery. METHODS We retrospectively reviewed an institutional database to identify patients who underwent primary debulking surgery for ovarian cancer at a single center between January 1, 2001 and May 31, 2019. Receiver operating characteristic curve and area under the receiver operating characteristic curve (AUC) were calculated. Five-fold cross-validation was applied to the multivariate model. Significant variables were assigned a 'BLOODS' (BLood transfusion Over an Ovarian cancer Debulking Surgery) score of +1 if present. A total BLOODS score was calculated for each patient, and the odds of receiving a transfusion was determined for each score. RESULTS Overall, 1566 patients met eligibility criteria; 800 (51%) underwent a peri-operative blood transfusion. Odds ratios (OR) were statistically significant for American Society of Anesthesiologists scores of 3 and 4 (OR 1.34, 95% confidence interval (95% CI) 1.09 to 1.63), pre-operative levels of cancer antigen 125 (CA125) (OR 2.43, 95% CI 1.98 to 2.99), platelets (OR 1.59, 95% CI 1.45 to 1.74), obesity (OR 0.76, 95% CI 0.60 to 0.96), presence of carcinomatosis (OR 2.45, 95% CI 1.93 to 3.11), bulky upper abdominal disease (OR 2.86, 95% CI 2.32 to 3.54), pre-operative serum albumin level (OR 0.31, 95% CI 0.24 to 0.40), and pre-operative hemoglobin level (OR 0.56, 95% CI 0.51 to 0.61). The corrected AUC was 0.748 (95% CI 0.693 to 0.804). BLOODS scores of 0 and 5 corresponded to 11% and 73% odds, respectively, of receiving a peri-operative blood transfusion. CONCLUSIONS We developed a universal pre-operative scoring system, the BLOODS score, to help identify patients with ovarian cancer who would benefit from surgical planning and blood-saving techniques. The BLOODS score was directly proportional to the American Society of Anesthesiologists score, presence of upper abdominal disease, carcinomatosis, CA125 level, and platelets level. We believe this model can help physicians with surgical planning and can benefit patient outcomes.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael Kim
- Department of Obstetrics and Gynecology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Clarissa Lam
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sushmita Gordhandas
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ahmed Al-Niaimi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Rachel N Grisham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
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Wakiya T, Ishido K, Kimura N, Nagase H, Kanda T, Kubota S, Fujita H, Takahashi Y, Yamamoto T, Chida K, Saito J, Hirota K, Hakamada K. Postoperative long‑term outcomes of acute normovolemic hemodilution in pancreatic cancer: A propensity score matching analysis. Oncol Lett 2024; 27:236. [PMID: 38601182 PMCID: PMC11005082 DOI: 10.3892/ol.2024.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/31/2024] [Indexed: 04/12/2024] Open
Abstract
Acute normovolemic hemodilution (ANH) is a useful intraoperative blood conservation technique. However, the impact on long-term outcomes in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study investigated the impact of ANH on long-term outcomes in patients with PDAC undergoing radical surgery. Data from 155 resectable PDAC cases were collected. Patients were categorized according to whether or not they had received intraoperative allogeneic blood transfusion (ABT) or ANH. Postoperative complications, recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ANH. A total of 44 patients (28.4%) were included in the ANH group and 30 patients (19.4%) were included in the ABT group; 81 (52.3%) patients, comprising the standard management (STD) group, received neither ANH nor ABT. The ABT group had the worst prognosis among them. Before PSM, ANH was significantly associated with decreased RFS (P=0.043) and DSS (P=0.029) compared with the STD group before applying Bonferroni correction; however, no significant difference was observed after applying Bonferroni correction. Cox regression analysis identified ANH as an independent prognostic factor for RFS [relative risk (RR), 1.696; P=0.019] and DSS (RR, 1.876; P=0.009). After PSM, the ANH group exhibited less favorable RFS [median survival time (MST), 12.1 vs. 18.1 months; P=0.097] and DSS (MST, 32.1 vs. 50.5 months; P=0.097) compared with the STD group; however, these differences were not statistically significant. In conclusion, while ANH was not as harmful as ABT, it exhibited potentially more negative effects on long-term postoperative outcomes in PDAC than STD.
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Affiliation(s)
- Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Taishu Kanda
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Shunsuke Kubota
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Hiroaki Fujita
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Yoshiya Takahashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Takeshi Yamamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Kohei Chida
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
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Yang J, Zhang J, Luo J, Ouyang J, Qu Q, Wang Q, Si Y. Safe and Effective Blood Preservation Through Acute Normovolemic Hemodilution and Low-Dose Tranexamic Acid in Open Partial Hepatectomy. J Pain Res 2023; 16:3905-3916. [PMID: 38026458 PMCID: PMC10657755 DOI: 10.2147/jpr.s426872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/21/2023] [Indexed: 12/01/2023] Open
Abstract
Objective In this study, we evaluated the efficacy of tranexamic acid (TXA) and acute normovolemic hemodilution (ANH) with 6% hydroxyethyl starch (130/0.4) in minimizing blood loss during open partial liver resection. Coagulation function was assessed using thromboelastography (TEG) and hemostasis tests, while renal function changes were tracked through serum creatinine values post-surgery. Methods Thirty patients undergoing open partial liver resection were allocated to two groups: Group T received TXA + ANH, and Group A received ANH alone. Blood was drawn from the radial artery under general anesthesia. Both groups received peripheral vein injections of 6% hydroxyethyl starch 130/0.4. Group T additionally received intravenous TXA. Primary outcomes included blood loss and allogeneic blood transfusions. TEG assessed coagulation status and renal function was monitored. Results Group T demonstrated superior outcomes compared to Group A. Group T had significantly lower intraoperative blood loss (700 mL vs 1200 mL) and a lower bleeding rate per kilogram of body weight (13.3 mL/kg vs 20.4 mL/kg). Coagulation parameters favored Group T, with higher TEG maximum amplitude (55.91 mm vs 45.88 mm) and lower activated partial thromboplastin time (38.04 seconds vs 41.49 seconds). Neither group experienced acute renal injury or kidney function deficiency during hospitalization. Conclusion TXA and ANH in a small dose during liver resection stabilize clotting, reduce blood loss by 6% compared to hydroxyethyl starch 130/0.4, and do not affect renal function.
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Affiliation(s)
- Jian Yang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Jing Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Jiayan Luo
- Department of Anesthesiology, People’s Hospital of Yanting, Sichuan, 621600, People’s Republic of China
| | - Jie Ouyang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Qicai Qu
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Qitao Wang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Yongyu Si
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
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Chen P, Zhang XH, Wang Y, Lin XZ, Kang DZ, Lin QS. The role of acute normovolemic hemodilution in reducing allogeneic blood transfusion in glioblastoma surgery: a case-control study. Chin Neurosurg J 2023; 9:31. [PMID: 37957765 PMCID: PMC10641951 DOI: 10.1186/s41016-023-00343-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/24/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) was first introduced in glioblastoma surgery, and its role in reducing allogeneic blood transfusion was investigated in this study. METHODS This study enrolled supratentorial glioblastoma patients who received total resection. In the ANH group, the patients were required to draw blood before the operation, and the blood will be transfused back to the patient during the operation. The association between ANH and clinical features was investigated. RESULTS Sixty supratentorial glioblastoma patients were enrolled in this study, 25 patients were allocated in the ANH group, and another 35 patients were included in the control group. ANH dramatically reduced the need for allogeneic blood transfusion (3 [12%] vs 12 [34.3%], P = 0.049), and the blood transfusion per total of patients was dramatically decreased by the application of ANH (0.40 ± 1.15 units vs 1.06 ± 1.59 units, P = 0.069). Furthermore, ANH also markedly reduced the requirement of fresh frozen plasma (FFP) transfusion (2 [8%] vs 11 [31.4%], P = 0.030) and the volume of FFP transfusion per total of patients (32.00 ± 114.46 mL vs 115.71 ± 181.00 mL, P = 0.033). The complication rate was similar between the two groups. CONCLUSIONS ANH was a safe and effective blood conservation technique in glioblastoma surgery.
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Affiliation(s)
- Ping Chen
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
| | - Xin-Huang Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
| | - Ying Wang
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
| | - Xian-Zhong Lin
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Rd, Taijiang District, Fuzhou, 350005, Fujian, China.
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350209, Fujian, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Fujian Provincial Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
| | - Qing-Song Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Rd, Taijiang District, Fuzhou, 350005, Fujian, China.
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350209, Fujian, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Fujian Provincial Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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Ye H, Wu H, Li B, Zuo P, Chen C. Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:89. [PMID: 36949393 PMCID: PMC10032024 DOI: 10.1186/s12871-023-02042-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Perioperative bleeding and allogeneic blood transfusion are generally thought to affect the outcomes of patients. This meta-analysis aimed to determine the benefits and risks of several cardiovascular interventions in patients undergoing hepatectomy. METHODS In this systematic review and meta-analysis, randomised controlled trials (RCTs) were searched in the Cochrane Library, Medline, Embase, and Web of Science to February 02, 2023. RCTs focused on cardiovascular interventions aimed at reducing blood loss or blood transfusion requirements during hepatectomy were included. The primary outcomes were perioperative blood loss amount, number of patients requiring allogeneic blood transfusion and overall occurrence of postoperative complications. The secondary outcomes were operating time, perioperative mortality rate, postoperative liver and kidney function and length of hospital stay. RESULTS Seventeen RCTs were included in the analysis. A total of 841 patients who underwent hepatectomy in 10 trials were included in the comparative analysis between low central venous pressure (CVP) and control groups. The forest plots showed a low operative bleeding volume [(mean difference (MD): -409.75 mL, 95% confidence intervals (CI) -616.56 to -202.94, P < 0.001], reduced blood transfusion rate [risk ratio (RR): 0.47, 95% CI 0.34 to 0.65, P < 0.001], shortened operating time (MD: -13.42 min, 95% CI -22.59 to -4.26, P = 0.004), and fewer postoperative complications (RR: 0.76, 95% CI 0.58 to 0.99, P = 0.04) in the low CVP group than in the control group. Five and two trials compared the following interventions, respectively: 'acute normovolaemic haemodilution (ANH) vs control' and 'autologous blood donation vs control'. ANH and autologous blood donation could not reduce the blood loss amount but greatly decreased the number of patients requiring allogeneic blood transfusion. No benefits were found in the rate of mortality and length of postoperative hospital stay in any of the comparisons. CONCLUSION Lowering the CVP seems to be effective and safe in adult patients undergoing hepatectomy. ANH and autologous blood donation should be used as a part of blood management for suitable patients in certain circumstances. TRIAL REGISTRATION PROSPERO, CRD42022314061.
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Affiliation(s)
- Hui Ye
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China.
| | - Hanghang Wu
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Bin Li
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China
| | - Pengfei Zuo
- Department of Cardiology, ZhongDa Hospital, Southeast University, Nanjing, China
| | - Chaobo Chen
- Department of General Surgery, Xishan People's Hospital of Wuxi city, No. 1128 Dacheng Road, Xishan District, Wuxi, 214105, China.
- Department of Hepatic-Biliary-Pancreatic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
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Ratnayake S, Subasinghe D, Dassanayake V, Sivaganesh S. Parenchymal-sparing hepatectomy for multiple bilobar colorectal liver metastases in a Jehovah's witness: a case report. JOURNAL OF LIVER CANCER 2023; 23:202-205. [PMID: 37384029 PMCID: PMC10202246 DOI: 10.17998/jlc.2023.01.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/19/2023] [Accepted: 01/27/2023] [Indexed: 06/30/2023]
Abstract
Parenchymal-sparing hepatectomy (PSH), though technically challenging, is emerging as a choice of treatment for colorectal liver metastases (CRLM). PSH in Jehovah's witness (JW) patients, for whom transfusion is not an option, involves complex surgical and medicolegal issues. A 52-year-old JW male with synchronous, multiple, bilobar liver metastases from a rectal adenocarcinoma was referred following neoadjuvant chemotherapy. At surgery, 10 metastatic deposits were observed and confirmed by intraoperative ultrasonography. Parenchymal-sparing non-anatomical resections were performed using a cavitron ultrasonic aspirator with the application of intermittent Pringle maneuvres. Histology confirmed multiple CRLMs with tumor-free resection margins. PSH is increasingly employed for CRLMs to preserve residual liver volume and minimize morbidity without compromising oncological outcomes. It is technically challenging, especially in the presence of bilobar, multi-segmental disease. This case illustrates the feasibility of performing complex hepatic surgery in special patient groups by meticulous planning and preparation involving multiple specialties and the patient.
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Affiliation(s)
- Shehan Ratnayake
- University Surgical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Duminda Subasinghe
- University Surgical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Vihara Dassanayake
- University Surgical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Sivasuriya Sivaganesh
- University Surgical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Martel G, Lenet T, Wherrett C, Carrier FM, Monette L, Workneh A, Brousseau K, Ruel M, Chassé M, Collin Y, Vandenbroucke-Menu F, Hamel-Perreault É, Perreault MA, Park J, Lim S, Maltais V, Leung P, Gilbert RWD, Segedi M, Abou-Khalil J, Bertens KA, Balaa FK, Ramsay T, Fergusson DA. Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:38. [PMID: 36653812 PMCID: PMC9848035 DOI: 10.1186/s13063-022-07008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.
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Affiliation(s)
- Guillaume Martel
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tori Lenet
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christopher Wherrett
- grid.28046.380000 0001 2182 2255Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON Canada
| | - François-Martin Carrier
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada ,grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Leah Monette
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Aklile Workneh
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Karine Brousseau
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Monique Ruel
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Michaël Chassé
- grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Yves Collin
- grid.411172.00000 0001 0081 2808Division of General Surgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Franck Vandenbroucke-Menu
- grid.410559.c0000 0001 0743 2111Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Department of Surgery - Centre Hospitalier de l’Université de Montréal, Montréal, QC Canada
| | - Élodie Hamel-Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Michel-Antoine Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Jeieung Park
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Shirley Lim
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Véronique Maltais
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Philemon Leung
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Richard W. D. Gilbert
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Maja Segedi
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Jad Abou-Khalil
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A. Bertens
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Fady K. Balaa
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Dean A. Fergusson
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
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9
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Li J, Xia Y, Jin S, Dong H, Zhao P, Jiang H, Hu R. Effects of acute normovolemic hemodilution on allogeneic blood transfusion & coagulation in orthognathic surgery: A randomized study. Transfusion 2023; 63:125-133. [PMID: 36342237 DOI: 10.1111/trf.17178] [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: 01/24/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) is one of the important techniques predominantly used in cardiac, hepatic, and vascular surgery for decreasing allogeneic blood transfusion. However, the effect of ANH in orthognathic surgery has been rarely studied. Therefore, this study aims to assess the ANH-mediated reduction in the allogeneic red blood cell transfusion for orthognathic surgery patients. STUDY DESIGN AND METHODS In this single-center study, 18-80 years old patients were recruited. Patients with hemoglobin ≥11 g/dL and normal coagulation function were randomly divided into ANH or standard treatment group. RESULTS Ninety six patients underwent ANH, and 101 patients received standard treatment. No differences in demographic or major pre-operative characteristics were observed between the two groups. One patient in the ANH and three patients in the standard treatment group received allogeneic blood [3(2.97%) vs. 1(1.16%), control vs. ANH, p = .395]. Multivariate logistic regression analysis revealed that ANH treatment was not associated with transfusion of allogeneic blood (p = .763). After retransfusing autologous blood, PT and APTT in the ANH group significantly increased compared to standard treatment group (PT: -1.73 ± 1.09 vs. -2.15 ± 1.06, p = .035; APTT: -6.39 ± 5.76 vs. -8.16 ± 5.70, p = .031; control vs. ANH). No significant differences between the two groups were observed for changes in coagulation parameters at first postoperative day. However, platelet counts in the ANH group decreased compared to the standard group. No significant difference in major adverse outcomes was observed between the two groups. CONCLUSION ANH did not reduce the incidence of allogeneic transfusion in patients undergoing orthognathic surgery.
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Affiliation(s)
- Jiayun Li
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
| | - Yangyang Xia
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
| | - Shanliang Jin
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
| | - Hui Dong
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
| | - PengCheng Zhao
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
| | - Hong Jiang
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
| | - Rong Hu
- Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai, China
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10
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Karanicolas PJ, Lin Y, McCluskey S, Roke R, Tarshis J, Thorpe KE, Ball CG, Chaudhury P, Cleary SP, Dixon E, Eeson G, Moulton CA, Nanji S, Porter G, Ruo L, Skaro AI, Tsang M, Wei AC, Guyatt G. Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial. BMJ Open 2022; 12:e058850. [PMID: 35210348 PMCID: PMC8883280 DOI: 10.1136/bmjopen-2021-058850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched. METHODS AND ANALYSIS This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival. ETHICS AND DISSEMINATION This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT02261415.
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Affiliation(s)
- Paul Jack Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Roke
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Chad G Ball
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Québec, Canada
| | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elijah Dixon
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gareth Eeson
- Department of Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carol-Anne Moulton
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Geoff Porter
- Department of Surgery, Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Leyo Ruo
- Department of Surgery, Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
- Deparment of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anton I Skaro
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Melanie Tsang
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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11
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Al Khaldi M, Gryspeerdt F, Carrier FM, Bouchard C, Simoneau È, Rong Z, Plasse M, Létourneau R, Dagenais M, Roy A, Lapointe R, Massicotte L, Vandenbroucke-Menu F, Rioux-Massé B, Turcotte S. Effect of intraoperative hypovolemic phlebotomy on transfusion and clinical outcomes in patients undergoing hepatectomy: a retrospective cohort study. Can J Anaesth 2021; 68:980-990. [PMID: 33945107 PMCID: PMC8175312 DOI: 10.1007/s12630-021-01958-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/03/2020] [Accepted: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is no consensus on how to best achieve a low central venous pressure during hepatectomy for the purpose of reducing blood loss and red blood cell (RBC) transfusions. We analyzed the associations between intraoperative hypovolemic phlebotomy (IOHP), transfusions, and postoperative outcomes in cancer patients undergoing hepatectomy. METHODS Using surgical and transfusion databases of patients who underwent hepatectomy for cancer at one institution (11 January 2011 to 22 June 2017), we retrospectively analyzed associations between IOHP and RBC transfusion on the day of surgery (primary outcome), and with total perioperative transfusions, intraoperative blood loss, and postoperative complications (secondary outcomes). We fitted logistic regression models by inverse probability of treatment weighting to adjust for confounders and reported adjusted odds ratio (aOR). RESULTS There were 522 instances of IOHP performed during 683 hepatectomies, with a mean (standard deviation) volume of 396 (119) mL. The IOHP patients had a 6.9% transfusion risk on the day of surgery compared with 12.4% in non-IOHP patients (aOR, 0.53; 95% confidence interval [CI], 0.29 to 0.98; P = 0.04). Total perioperative RBC transfusion tended to be lower in IOHP patients compared with non-IOHP patients (14.9% vs 22.4%, respectively; aOR, 0.72; 95% CI, 0.44 to 1.16; P = 0.18). In patients with a predicted risk of ≥ 47.5% perioperative RBC transfusion, 24.6% were transfused when IOHP was used compared with 56.5% without IOHP. The incidence of severe postoperative complications (Clavien-Dindo scores ≥ 3) was similar in patients whether or not IOHP was performed (15% vs 16% respectively; aOR, 0.97; 95% CI, 0.53 to 1.54; P = 0.71). CONCLUSIONS The use of IOHP during hepatectomy was associated with less RBCs transfused on the same day of surgery. Trials comparing IOHP with other techniques to reduce blood loss and transfusion are needed in liver surgery.
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Affiliation(s)
- Maher Al Khaldi
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Filip Gryspeerdt
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
- Critical Care Service, Department of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Claudia Bouchard
- Department of Hematology-Transfusion Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Ève Simoneau
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Zhixia Rong
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Marylène Plasse
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Richard Létourneau
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Michel Dagenais
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - André Roy
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Réal Lapointe
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Franck Vandenbroucke-Menu
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Benjamin Rioux-Massé
- Department of Hematology-Transfusion Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Simon Turcotte
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada.
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12
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McCullough J. Patient Blood Management. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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13
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Boerner T, Tanner E, Filippova O, Zhou QC, Iasonos A, Tew WP, O'Cearbhaill RE, Grisham RN, Gardner GJ, Sonoda Y, Abu-Rustum NR, Zivanovic O, Long Roche K, Afonso AM, Fischer M, Chi DS. Survival outcomes of acute normovolemic hemodilution in patients undergoing primary debulking surgery for advanced ovarian cancer: A Memorial Sloan Kettering Cancer Center Team Ovary study. Gynecol Oncol 2021; 160:51-55. [PMID: 33213899 PMCID: PMC8378264 DOI: 10.1016/j.ygyno.2020.10.042] [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: 09/23/2020] [Accepted: 10/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. METHODS We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012-04/2017). Standard statistical tests were used. RESULTS There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618-1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317-1.092); p = 0.093]. CONCLUSIONS ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits.
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Affiliation(s)
- Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Edward Tanner
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Olga Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William P Tew
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Roisin E O'Cearbhaill
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Rachel N Grisham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Anoushka M Afonso
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA; Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary Fischer
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA; Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA.
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14
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Chen P, Wang Y, Zhang XH, Kang DZ, Lin XZ, Lin QS. The Use of Acute Normovolemic Hemodilution in Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 148:e209-e217. [PMID: 33385596 DOI: 10.1016/j.wneu.2020.12.110] [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: 11/24/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The occurrence of coronavirus disease 2019 (COVID-19) has overwhelmed the blood supply chain worldwide and severely influenced clinical procedures with potential massive blood loss, such as clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH). Whether acute normovolemic hemodilution (ANH) is safe and effective in aneurysm clipping remains largely unknown. METHODS Patients with aSAH who underwent clipping surgery within 72 hours from bleeding were included. The patients in the ANH group received 400 mL autologous blood collection, and the blood was returned as needed during surgery. The relationships between ANH and perioperative allogeneic blood transfusion, postoperative outcome, and complications were analyzed. RESULTS Sixty-two patients with aSAH were included between December 2019 and June 2020 (20 in the ANH group and 42 in the non-ANH group). ANH did not reduce the need of perioperative blood transfusion (3 [15%] vs. 5 [11.9%]; P = 0.734). However, ANH significantly increased serum hemoglobin levels on postoperative day 1 (11.5 ± 2.5 g/dL vs. 10.3 ± 2.0 g/dL; P = 0.045) and day 3 (12.1 ± 2.0 g/dL vs. 10.7 ± 1.3 g/dL; P = 0.002). Multivariable analysis indicated that serum hemoglobin level on postoperative day 1 (odds ratio, 0.895; 95% confidence interval, 0.822-0.973; P = 0.010) was an independent risk factor for unfavorable outcome, and receiver operating characteristic curve analysis showed that it had a comparable predictive power to World Federation of Neurosurgical Societies grade (Z = 0.275; P > 0.05). CONCLUSIONS ANH significantly increased postoperative hemoglobin levels, and it may hold the potential to improve patients' outcomes. Routine use of ANH should be considered in aneurysm clipping surgery.
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Affiliation(s)
- Ping Chen
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Ying Wang
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xin-Huang Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Fujian Neuro-Medicine Center, Fuzhou, Fujian, China; Key Clinical Specialty Construction of Fujian, Fuzhou, Fujian, China
| | - Xian-Zhong Lin
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qing-Song Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Fujian Neuro-Medicine Center, Fuzhou, Fujian, China; Key Clinical Specialty Construction of Fujian, Fuzhou, Fujian, China.
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15
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Quan B, Zhang WG, Serenari M, Liang L, Xing H, Li C, Wang MD, Lau WY, Schwartz M, Pawlik TM, Cescon M, Wu MC, Shen F, Yang T. A novel online calculator to predict perioperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma: an international multicenter study. HPB (Oxford) 2020; 22:1711-1721. [PMID: 32340856 DOI: 10.1016/j.hpb.2020.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND To develop an easy-to-use model to predict the probability of perioperative blood transfusion (PBT) in patients undergoing liver resection for hepatocellular carcinoma (HCC). METHOD 878 patients from Eastern Hepatobiliary Surgery Hospital of Shanghai were enrolled in the training cohort, while 691 patients from Tongji Hospital of Wuhan and 364 patients from two hospitals from Europe and America served as the Eastern and Western external validation cohorts, respectively. Independent predictors of PBT were identified and used for the nomogram construction. The predictive performance of the model was assessed using the concordance index (C-index) and calibration plot, and externally validated using the two independent cohorts. This model was compared with four currently available prediction risk scores. RESULTS Eight preoperative variables were identified as independent predictors of PBT, which were incorporated into the new nomogram model, with a C-index of 0.833 and a well-fitted calibration plot. The nomogram performed well on the externally Eastern and Western validation cohorts (C-indexes: 0.786 and 0.777). The discriminatory ability of the nomogram was superior to the four currently available prediction scores (C-indexes: 0.833 vs. 0.671-0.770). The nomogram was programmed into an online calculator, which is available at http://www.asapcalculate.top/Cal3_en.html. CONCLUSION A nomogram model, using an easy-to-access website, can be used to calculate the PBT risk and identify which patients undergoing HCC resection are at high risks of PBT and can benefit most by using blood conservation techniques.
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Affiliation(s)
- Bing Quan
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China; Department of Clinical Medicine, Second Military Medical University (Naval Medical University), ShanghaiChina
| | - Wan-Guang Zhang
- Department of Hepatic Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Matteo Serenari
- Department of Medical and Surgical Sciences, General Surgery and Transplantation Unit, University of Bologna, Italy
| | - Lei Liang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Hao Xing
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Chao Li
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Ming-Da Wang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Wan Yee Lau
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China; Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T, Hong Kong
| | - Myron Schwartz
- Liver Cancer Program, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Timothy M Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, United States
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, General Surgery and Transplantation Unit, University of Bologna, Italy
| | - Meng-Chao Wu
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Feng Shen
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China.
| | - Tian Yang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China.
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You GX, Li BT, Wang Z, Wang Q, Wang Y, Zhao JX, Zhao L, Zhou H. Effects of different plasma expanders on rats subjected to severe acute normovolemic hemodilution. Mil Med Res 2020; 7:55. [PMID: 33172500 PMCID: PMC7656672 DOI: 10.1186/s40779-020-00282-4] [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: 01/27/2020] [Accepted: 10/18/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Plasma expanders are widely used for acute normovolemic hemodilution (ANH). However, existing studies have not focused on large-volume infusion with colloidal plasma expanders, and there is a lack of studies that compare the effects of different plasma expanders. METHODS The viscosity, hydrodynamic radius (Rh) and colloid osmotic pressure (COP) of plasma expanders were determined by a cone-plate viscometer, Zetasizer and cut-off membrane, respectively. Sixty male rats were randomized into five groups with Gelofusine (Gel), Hydroxyethyl Starch 200/0.5 (HES200), Hydroxyethyl Starch 130/0.4 (HES130), Hydroxyethyl Starch 40 (HES40), and Dextran40 (Dex40), with 12 rats used in each group to build the ANH model. ANH was performed by the withdrawal of blood and simultaneous infusion of plasma expanders. Acid-base, lactate, blood gas and physiological parameters were detected. RESULTS Gel had a lower intrinsic viscosity than HES200 and HES130 (P < 0.01), but at a low shear rate in a mixture of colloids, red cells and plasma, Gel had a higher viscosity (P < 0.05 or P < 0.01, respectively). For hydroxyethyl starch plasma expanders, the COP at a certain concentration decreases from 11.1 mmHg to 6.1 mmHg with the increase of Rh from 10.7 nm to 20.2 nm. A severe ANH model, with the hematocrit of 40% of the baseline level, was established and accompanied by disturbances in acid-base, lactate and blood gas parameters. At the end of ANH and 60 min afterward, the Dex40 group showed a worse outcome in maintaining the acid-base balance and systemic oxygenation compared to the other groups. The systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) decreased significantly in all groups at the end of ANH. The DBP and MAP in the Dex40 group further decreased 60 min after the end of ANH. During the process of ANH, the Dex40 group showed a drop and recovery in SBP, DBP and MAP. The DBP and MAP in the HES200 group were significantly higher than those in the other groups at some time points (P < 0.05 or P < 0.01). CONCLUSION Gel had a low intrinsic viscosity but may increase the whole blood viscosity at low shear rates. Rh and COP showed a strong correlation among hydroxyethyl starch plasma expanders. Dex40 showed a worse outcome in maintaining the acid-base balance and systemic oxygenation compared to the other plasma expanders. During the process of ANH, Dex40 displayed a V-shaped recovery pattern for blood pressure, and HES200 had the advantage in sustaining the DBP and MAP at some time points.
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Affiliation(s)
- Guo-Xing You
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China
| | - Bing-Ting Li
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China
| | - Zhen Wang
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China
| | - Quan Wang
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China
| | - Ying Wang
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China
| | - Jing-Xiang Zhao
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China
| | - Lian Zhao
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China.
| | - Hong Zhou
- Institute of Health Service and Transfusion Medicine, Bejing, 100850, China.
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17
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Putchakayala K, DiFronzo LA. Acute Hemodilution is Safe in Patients with Comorbid Illness Undergoing Partial Hepatectomy. Am Surg 2020. [DOI: 10.1177/000313481307901028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Despite increased use of acute hemodilution (AH) to reduce perioperative blood transfusion in patients undergoing partial hepatectomy, there is a lack of data on safety in those with comorbid medical illness. We performed a retrospective review of 96 patients undergoing partial hepatectomy with AH and low central venous pressure (CVP) anesthesia. The cohort was compared with 63 patients undergoing partial hepatectomy using standard anesthetic management (SA) and low CVP anesthesia. All were American Society of Anesthesiologists physical status 3 or 4. 58 per cent were baseline hypertensive on medication. Hepatic resection was predominantly performed for metastatic colorectal (41%) and primary hepatic (32%) cancer. Forty per cent underwent major hepatectomy. The mean volume of blood removed for AH was 497 mL (range, 0 to 1 L). Most achieved low CVP (AH 90% vs SA 84%, P = 0.3). Blood loss was lower with AH (mean 480 mL vs 904 mL, P < 0.001). Blood transfusion rate was 74 per cent lower with AH ( P < 0.001). There was no difference in cardiac, respiratory, renal, or overall complications with AH compared with SA. Acute hemodilution is well tolerated by patients with comorbid illness undergoing partial hepatectomy, favoring ongoing use and further study.
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Affiliation(s)
- Krishna Putchakayala
- Department of General Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - L. Andrew DiFronzo
- Department of General Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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18
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Nobre LV, Garcia LV. [Role of acute hemodilution in blood transfusion rate in patients submmited to scoliosis surgery: observational retrospective study]. Rev Bras Anestesiol 2020; 70:209-214. [PMID: 32493689 DOI: 10.1016/j.bjan.2019.12.014] [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: 05/27/2019] [Revised: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The study assessed the role of acute hemodilution in the blood transfusion rate in patients submitted to surgical treatment of scoliosis. METHODS Retrospective observational study performed at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC-FMRP?USP). Medical charts of patients submitted to elective correction of scoliosis between January 1996 and December 2016 were analyzed. Variables assessed were: age, weight, sex, presence of comorbidities, data regarding anesthesia and surgery, lab data, adverse events and blood transfusion rate. The final sample consisted of 33 procedures performed by the same anesthesiologist and same surgeon, divided into two groups: Hemodilution Group (n = 16) and Control Group (n = 17). Indication of acute normovolemic hemodilution was determined by patient refusal of blood transfusion for religious reasons. RESULTS The sample was statistically homogeneous and the groups were compared in terms of the attributes analyzed. The volume of homologous blood used by the Hemodilution Group was significantly lower than the Control Group (p = 0.0016). The percentage of patients who required transfusion was 12.5% in the Hemodilution Group, while it was 70.69% (p = 0.0013) in the Control Group. Upon hospital discharge, mean values of hemoglobin and hematocrit between groups did not present significant differences (p = 0.0679; p = 0.1027, respectively). CONCLUSIONS Acute normovolemic hemodilution, in scoliosis correction surgeries reduces blood transfusion rates, meeting patient needs without increasing adverse events or infection rates.
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Affiliation(s)
- Layana Vieira Nobre
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor pelo Programa de Pós-Graduação em Ciências da Saúde Aplicadas ao Aparelho Locomotor, Ribeirão Preto, SP, Brasil.
| | - Luis Vicente Garcia
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto, SP, Brasil
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19
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Nobre LV, Garcia LV. Role of acute hemodilution in blood transfusion rate in patients submitted to scoliosis surgery: observational retrospective study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32493689 PMCID: PMC9373322 DOI: 10.1016/j.bjane.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and objectives The study assessed the role of acute hemodilution in the blood transfusion rate in patients submitted to surgical treatment of scoliosis. Methods Retrospective observational study performed at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC-FMRP–USP). Medical charts of patients submitted to elective correction of scoliosis between January 1996 and December 2016 were analyzed. Variables assessed were: age, weight, sex, presence of comorbidities, data regarding anesthesia and surgery, lab data, adverse events and blood transfusion rate. The final sample consisted of 33 procedures performed by the same anesthesiologist and same surgeon, divided into two groups: Hemodilution Group (n = 16) and Control Group (n = 17). Indication of acute normovolemic hemodilution was determined by patient refusal of blood transfusion for religious reasons. Results The sample was statistically homogeneous and the groups were compared in terms of the attributes analyzed. The volume of homologous blood used by the Hemodilution Group was significantly lower than the Control Group (p = 0.0016). The percentage of patients who required transfusion was 12.5% in the Hemodilution Group, while it was 70.69% (p = 0.0013) in the Control Group. Upon hospital discharge, mean values of hemoglobin and hematocrit between groups did not present significant differences (p = 0.0679; p = 0.1027, respectively). Conclusions Acute normovolemic hemodilution, in scoliosis correction surgeries, reduces blood transfusion rates, meeting patient needs without increasing adverse events or infection rates.
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20
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Barth RJ. Profiles of Surgical Entrepreneurs. J Am Coll Surg 2020; 230:845-852. [PMID: 32147486 DOI: 10.1016/j.jamcollsurg.2019.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Richard J Barth
- Section of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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21
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Martel G, Baker L, Wherrett C, Fergusson DA, Saidenberg E, Workneh A, Saeed S, Gadbois K, Jee R, McVicar J, Rao P, Thompson C, Wong P, Abou Khalil J, Bertens KA, Balaa FK. Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility. Br J Surg 2020; 107:812-823. [PMID: 31965573 DOI: 10.1002/bjs.11463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/28/2019] [Accepted: 11/15/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial. METHODS Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL). RESULTS A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326). CONCLUSION Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - L Baker
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - C Wherrett
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - D A Fergusson
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - E Saidenberg
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - A Workneh
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Saeed
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K Gadbois
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - R Jee
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J McVicar
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Rao
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - C Thompson
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Wong
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Abou Khalil
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - K A Bertens
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - F K Balaa
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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22
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Short-term Preoperative Diet Decreases Bleeding After Partial Hepatectomy: Results From a Multi-institutional Randomized Controlled Trial. Ann Surg 2019; 269:48-52. [PMID: 29489484 DOI: 10.1097/sla.0000000000002709] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Our previous case series suggested that a 1-week, low-calorie and low-fat diet was associated with decreased intraoperative blood loss in patients undergoing liver surgery. OBJECTIVE The current study evaluates the effect of this diet in a randomized controlled trial. METHODS We randomly assigned 60 patients with a body mass index ≥25 kg/m(2) to no special diet or an 800-kcal, 20 g fat, and 70 g protein diet for 1 week before liver resection. Surgeons were blinded to diet assignment. Hepatic glycogen stores were evaluated using periodic acid Schiff (PAS) stains. RESULTS Ninety four percent of the patients complied with the diet. The diet group consumed fewer daily total calories (807 vs 1968 kcal, P < 0.001) and fat (21 vs 86 g, P < 0.001) than the no diet group. Intraoperative blood loss was less in the diet group: mean blood loss 452 vs 863 mL (P = 0.021). There was a trend towards decreased transfusion in the diet group (138 vs 322 mL, P = 0.06). The surgeon judged the liver to be easier to manipulate in the diet group: 1.86 versus 2.90, P = 0.004. Complication rate (20% vs 17%), length of stay (median 5 vs 4 days) and mortality did not differ between groups. There was no difference in hepatic steatosis between groups. There was less glycogen in hepatocytes in the diet group (PAS stain score 1.61 vs 2.46, P < 0.0001). CONCLUSIONS A short-course, low-fat, and low-calorie diet significantly decreases bleeding and makes the liver easier to manipulate in hepatic surgery.
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23
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Baker L, Bennett S, Rekman J, Workneh A, Wherrett C, Abou-Khalil J, Bertens KA, Balaa FK, Martel G. Hypovolemic phlebotomy in liver surgery is associated with decreased red blood cell transfusion. HPB (Oxford) 2019; 21:757-764. [PMID: 30501988 DOI: 10.1016/j.hpb.2018.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/25/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis. METHODS Consecutive patients who underwent liver resection at one institution (2010-2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression. RESULTS A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H2O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068-0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64-5.18, p = 0.0003), preoperative hemoglobin < 125 g/L (OR 6.02, 95% CI 3.44-10.56, p < 0.0001), and underlying liver disease (OR 2.24, 95% CI 1.27-3.95, p = 0.0051) were significantly associated with perioperative RBC transfusion. CONCLUSION Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.
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Affiliation(s)
- Laura Baker
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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24
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Fayed NA, Refaat EK, Shoream HA, Hakim SM. Acute normovolaemic haemodilution in cirrhotic patients undergoing major liver resection: Role of ROTEM. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Nirmeen A. Fayed
- Department of Anesthesia, National Liver Institute, Menofeya University, Egypt
| | - Emad K. Refaat
- Department of Anesthesia, National Liver Institute, Menofeya University, Egypt
| | - Hany A. Shoream
- Hepatobiliary Surgery, National Liver Institute, Menofeya University , Egypt
| | - Sameh M. Hakim
- Department of Anesthesia, Faculty of Medicine, Ain Shams University, Egypt
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25
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Lopez-Aguiar AG, Ethun CG, Pawlik TM, Tran T, Poultsides GA, Isom CA, Idrees K, Krasnick BA, Fields RC, Salem A, Weber SM, Martin RCG, Scoggins CR, Shen P, Mogal HD, Beal EW, Schmidt C, Shenoy R, Hatzaras I, Maithel SK. Association of Perioperative Transfusion with Recurrence and Survival After Resection of Distal Cholangiocarcinoma: A 10-Institution Study from the US Extrahepatic Biliary Malignancy Consortium. Ann Surg Oncol 2019; 26:1814-1823. [PMID: 30877497 PMCID: PMC10182408 DOI: 10.1245/s10434-019-07306-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Perioperative allogeneic blood transfusion is associated with poor oncologic outcomes in multiple malignancies. The effect of blood transfusion on recurrence and survival in distal cholangiocarcinoma (DCC) is not known. METHODS All patients with DCC who underwent curative-intent pancreaticoduodenectomy at 10 institutions from 2000 to 2015 were included. Primary outcomes were recurrence-free (RFS) and overall survival (OS). RESULTS Among 314 patients with DCC, 191 (61%) underwent curative-intent pancreaticoduodenectomy. Fifty-three patients (28%) received perioperative blood transfusions, with a median of 2 units. There were no differences in baseline demographics or operative data between transfusion and no-transfusion groups. Compared with no-transfusion, patients who received a transfusion were more likely to have (+) margins (28 vs 14%; p = 0.034) and major complications (46 vs 16%; p < 0.001). Transfusion was associated with worse median RFS (19 vs 32 months; p = 0.006) and OS (15 vs 29 months; p = 0.003), which persisted on multivariable (MV) analysis for both RFS [hazard ratio (HR) 1.8; 95% confidence interval (CI) 1.1-3.0; p = 0.031] and OS (HR 1.9; 95% CI 1.1-3.3; p = 0.018), after controlling for portal vein resection, estimated blood loss (EBL), grade, lymphovascular invasion (LVI), and major complications. Similarly, transfusion of ≥ 2 pRBCs was associated with lower RFS (17 vs 32 months; p < 0.001) and OS (14 vs 29 months; p < 0.001), which again persisted on MV analysis for both RFS (HR 2.6; 95% CI 1.4-4.5; p = 0.001) and OS (HR 4.0; 95% CI 2.2-7.5; p < 0.001). The RFS and OS of patients transfused 1 unit was comparable to patients who were not transfused. CONCLUSION Perioperative blood transfusion is associated with decreased RFS and OS after resection for distal cholangiocarcinoma, after accounting for known adverse pathologic factors. Volume of transfusion seems to exert an independent effect, as 1 unit was not associated with the same adverse effects as ≥ 2 units.
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Affiliation(s)
- Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | | | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Kim TY, Kim DW, Jeong MA, Jun JH, Min SJ, Shin SJ, Ha TK, Choi D. Effects of acute normovolemic hemodilution on healing of gastric anastomosis in rats. Ann Surg Treat Res 2018; 95:312-318. [PMID: 30505822 PMCID: PMC6255747 DOI: 10.4174/astr.2018.95.6.312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/21/2018] [Accepted: 06/29/2018] [Indexed: 11/30/2022] Open
Abstract
Purpose Acute normovolemic hemodilution (ANH) is an autologous transfusion method, using blood collected during surgery, to reduce the need for allogeneic blood transfusion. ANH is controversial because it may lead to various complications. Among the possible complications, anastomotic leakage is one that would have a significant effect on the operation outcome. However, the relationship between ANH and anastomotic site healing requires additional research. Therefore, we conducted this prospective study of ANH, comparing it with standard intraoperative management, undergoing gastric anastomosis in rats. Methods Sixteen Sprague-Dawley rats were randomly assigned to three groups: group A, surgery with ANH; group N, surgery with standard intraoperative management; and group C, sham surgery with standard intraoperative management. ANH was performed in group A animals by, removing 5.8–6.6 mL of blood and replacing it with 3 times as much crystalloid. All rats were enthanized on postoperative day 6, and histopathologic analyses were performed. Results The mean hematocrit values, after hemodilution were 22.0% (range, 18.0%–29.0%), group A; 33.0% (29.0%–35.0%), group N; and 32.5% (29.0%–34.0%), group C. There were significant differences between groups A and N (P = 0.019, P = 0.009, P = 0.004, P = 0.039, and P = 0.027), and between groups N and C (P = 0.006, P = 0.027, P = 0.04, P = 0.008, and P = 0.009) with respect to inflammatory cell numbers, neovascularization, fibroblast numbers, edema and necrosis, respectively; there were no differences between groups A and N. Conclusion In rat model, anastomotic complications did not increase in the ANH group, compared with the standard intraoperative management group.
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Affiliation(s)
- Tae Yeon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi Ae Jeong
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jong Hun Jun
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Jeong Min
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Su-Jin Shin
- Department of Pathology, Hanyang University College of Medicine, Seoul, Korea
| | - Tae Kyung Ha
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Dongho Choi
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
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Koo BN, Kwon MA, Kim SH, Kim JY, Moon YJ, Park SY, Lee EH, Chae MS, Choi SU, Choi JH, Hwang JY. Korean clinical practice guideline for perioperative red blood cell transfusion from Korean Society of Anesthesiologists. Korean J Anesthesiol 2018; 72:91-118. [PMID: 30513567 PMCID: PMC6458508 DOI: 10.4097/kja.d.18.00322] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/27/2018] [Indexed: 01/28/2023] Open
Abstract
Background Considering the functional role of red blood cells (RBC) in maintaining oxygen supply to tissues, RBC transfusion can be a life-saving intervention in situations of severe bleeding or anemia. RBC transfusion is often inevitable to address intraoperative massive bleeding; it is a key component in safe perioperative patient management. Unlike general medical resources, packed RBCs (pRBCs) have limited availability because their supply relies entirely on voluntary donations. Additionally, excessive utilization of pRBCs may aggravate prognosis or increase the risk of developing infectious diseases. Appropriate perioperative RBC transfusion is, therefore, crucial for the management of patient safety and medical resource conservation. These concerns motivated us to develop the present clinical practice guideline for evidence-based efficient and safe perioperative RBC transfusion management considering the current clinical landscape. Methods This guideline was obtained after the revision and refinement of exemplary clinical practice guidelines developed in advanced countries. This was followed by rigorous evidence-based reassessment considering the healthcare environment of the country. Results This guideline covers all important aspects of perioperative RBC transfusion, such as preoperative anemia management, appropriate RBC storage period, and leukoreduction (removal of white blood cells using filters), reversal of perioperative bleeding tendency, strategies for perioperative RBC transfusion, appropriate blood management protocols, efforts to reduce blood transfusion requirements, and patient monitoring during a perioperative transfusion. Conclusions This guideline will aid decisions related to RBC transfusion in healthcare settings and minimize patient risk associated with unnecessary pRBC transfusion.
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Affiliation(s)
- Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Sang-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Tanner EJ, Filippova OT, Gardner GJ, Long Roche KC, Sonoda Y, Zivanovic O, Fischer M, Chi DS. A prospective trial of acute normovolemic hemodilution in patients undergoing primary cytoreductive surgery for advanced ovarian cancer. Gynecol Oncol 2018; 151:433-437. [PMID: 30336947 PMCID: PMC6615481 DOI: 10.1016/j.ygyno.2018.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/26/2018] [Accepted: 10/02/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Our objective was to determine the safety and efficacy of acute normovolemic hemodilution (ANH) to reduce the requirement for allogenic red blood cell (RBC) transfusions in patients undergoing primary cytoreduction for advanced ovarian cancer. METHODS Patients undergoing primary cytoreduction for advanced ovarian cancer were enrolled in a prospective trial assessing ANH at time of surgery. Intraoperative blood withdrawal was performed to a target hemoglobin of 8.0 g/dL. A standardized transfusion protocol first using autologous then allogenic blood was applied intraoperatively and throughout hospitalization according to institutional guidelines. The primary endpoint was to determine the overall rate of allogenic RBC transfusions in the intra- and postoperative periods. A predetermined allogenic RBC transfusion rate <35% was deemed a meaningful reduction from a 50% transfusion rate in historical controls. RESULTS Forty-one patients consented to participate. Median blood withdrawn during ANH was 1650 mL (range, 700-3000). Cytoreductive outcomes were as follows: 0 mm, 30 (73%); 1-10 mm, 8 (20%); and >10 mm, 3 (7%) residual disease. Estimated blood loss was 1000 mL (range, 150-2700). Fourteen patients (34%) received allogenic RBC transfusions intra- or postoperatively, meeting the primary endpoint. No patients were transfused outside protocol guidelines. The rate of ≥grade 3 complications (20%) and anastomotic leaks (7%) were similar to historical controls and met predefined safety thresholds. CONCLUSIONS For patients with advanced ovarian cancer undergoing primary cytoreductive surgery, ANH appears to reduce allogenic RBC transfusion rates versus historical controls without increasing perioperative complications. Further evaluation of the technique is warranted.
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Affiliation(s)
- Edward J Tanner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America.
| | - Olga T Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Kara C Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Mary Fischer
- Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
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Albu G, Sottas C, Dolci M, Walesa M, Peták F, Habre W. Cardiorespiratory Alterations Following Acute Normovolemic Hemodilution in a Pediatric and an Adult Porcine Model. Anesth Analg 2018; 126:995-1003. [DOI: 10.1213/ane.0000000000002175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Sims CR, Delima LR, Calimaran A, Hester R, Pruett WA. Validating the Physiologic Model HumMod as a Substitute for Clinical Trials Involving Acute Normovolemic Hemodilution. Anesth Analg 2018; 126:93-101. [PMID: 28863020 DOI: 10.1213/ane.0000000000002430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Blood conservation strategies and transfusion guidelines remain a heavily debated clinical topic. Previous investigational trials have shown that acute isovolemic hemodilution does not limit adequate oxygen delivery; however, a true critical hemoglobin level has never been investigated or defined due to safety concerns for human volunteers. Validated physiologic modeling may be useful to investigate hemodilution at critical hemoglobin levels without the ethical or safety hazards of clinical trials. Our hypothesis is that HumMod, an integrative physiological model, can replicate the cardiovascular and metabolic findings of previous clinical studies of acute isovolemic hemodilution and use coronary blood flow and coronary oxygen delivery in extreme hemodilution to predict a safety threshold. METHODS By varying cardiovascular and sizing parameters, unique individuals were generated to simulate a population using HumMod, an integrative mathematical model of human physiology. Hemodilution was performed by simultaneously hemorrhaging 500 mL aliquots of blood while infusing equal volumes of hetastarch, 5% albumin balanced salt solution, or triple volumes of lactated Ringer's solution over 10 minutes. Five hemodilution protocols reported over 3 studies were directly replicated with HumMod to compare and validate essential cardiovascular and metabolic responses to hemodilution in moderately healthy, awake adults. Cardiovascular parameters, mental status, arterial and mixed venous oxygen content, and oxyhemoglobin saturation were recorded after the removal of each aliquot. The outputs of this simulation were considered independent variables and were stratified by hemoglobin concentration at the time of measurement to assess hemoglobin as an independent predictor of hemodynamic and metabolic behavior. RESULTS The published reports exhibited discrepancies: Weiskopf saw increased heart rate and cardiac index, while Jones and Ickx saw no change in these variables. In HumMod, arterial pressure was maintained during moderate hemodilution due to decreases in peripheral resistance opposing increases in cardiac index. HumMod showed preserved ventilation through moderate hemodilution, compensated for by an increased oxygen extraction similar to the studies of Jones and Ickx. The simulation results qualitatively followed the clinical studies, but there were statistical differences. In more extreme hemodilution, HumMod had a lesser increase in cardiac index, which led to deficiencies in oxygen delivery and low venous saturation. In the simulations, coronary blood flow and oxygen delivery increase up to a critical hemoglobin threshold of 55-75 g/L in HumMod. In this range, coronary blood flow and oxygen delivery fell, leading to cardiac injury. The allowable amount of hemodilution before reaching the critical point is most closely correlated with nonmuscle mass (r = 0.69) and resting cardiac output (r = 0.67). CONCLUSIONS There were significant statistical differences in the model population and the clinical populations, but overall, the model responses lay within the clinical findings. This suggests our model is an effective replication of hemodilution in conscious, healthy adults. A critical hemoglobin range of 5.5-7.5 g/L was predicted and found to be highly correlated with nonmuscle mass and resting cardiac output.
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Affiliation(s)
| | | | | | - Robert Hester
- Department of Physiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - W Andrew Pruett
- Department of Physiology, University of Mississippi Medical Center, Jackson, Mississippi
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Yoshino O, Perini MV, Christophi C, Weinberg L. Perioperative fluid management in major hepatic resection: an integrative review. Hepatobiliary Pancreat Dis Int 2017; 16:458-469. [PMID: 28992877 DOI: 10.1016/s1499-3872(17)60055-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 04/10/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms "surgery", "anesthesia", "starch", "hydroxyethyl starch derivatives", "albumin", "gelatin", "liver resection", "hepatic resection", "fluids", "fluid therapy", "crystalloid", "colloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "acetate", and "lactate". Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed. CONCLUSIONS Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.
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Affiliation(s)
- Osamu Yoshino
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia.
| | - Marcos Vinicius Perini
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia; Anaesthesia Perioperative Pain Medicine Unit, University of Melbourne, Melbourne, Victoria, Australia
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Yang L, Wang HH, Wei FS, Ma LX. Evaluation of acute normovolemic hemodilution in patients undergoing intracranial meningioma resection: A quasi-experimental trial. Medicine (Baltimore) 2017; 96:e8093. [PMID: 28930850 PMCID: PMC5617717 DOI: 10.1097/md.0000000000008093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The aim of this study was to evaluate the safety of acute normovolemic hemodilution (ANH) for patients undergoing intracranial meningioma resection.Eighty patients (aged 48-65 years) with American Society of Anesthesiologists physical status I-II undergoing intracranial meningioma resection were included in this prospective observational study. The patients were randomly divided into group A (ANH group), which underwent a combination of ANH and intraoperative cell salvage (ICS), and group B (control group), which underwent ICS alone. The study parameters were recorded as baseline values before blood drainage (T0), after blood drainage (T1), and before (T2) and after (T3) retransfusion in group A. Whereas in group B, the same parameters were measured 10 minutes after anesthesia induction (T0), before surgery (T1), and before (T2) and after (T3) transfusion of autologous blood.When intraoperative blood loss was <2000 mL, the mean volume of homologous blood transfused in group A patients was 100.8 ± 82.3 mL, compared with the 190.0 ± 91.8 mL in group B. Reduction in homologous blood used in group A was statistically significant (P < .05). In group B, 15.1% patients received homologous blood, whereas only 5.9% patients received homologous blood in group A. The difference in heart rate between both groups at different time points was statistically nonsignificant (P > .05). The mean hemoglobin and hematocrit levels at T1 and T2 in group A were lower than in group B (P < .05). The prothrombin time and activated partial thromboplastin time in both groups were prolonged significantly after T2 (all P < .05), but were all within normal range. There were no significant differences in postoperative hospital stay, mortality, and postoperative infection between the 2 groups.For patients undergoing excision of intracranial meningioma, ANH is an effective procedure to reduce the need for allogeneic transfusions.
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Affiliation(s)
- Lei Yang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Hui-Hui Wang
- Department of Anesthesiology, Xinyu People's Hospital, Xinyu
| | - Fu-Sheng Wei
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - Long-Xian Ma
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
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Lemke M, Law CHL, Li J, Dixon E, Tun Abraham M, Hernandez Alejandro R, Bennett S, Martel G, Karanicolas PJ. Three-point transfusion risk score in hepatectomy. Br J Surg 2017; 104:434-442. [PMID: 28079259 DOI: 10.1002/bjs.10416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/27/2016] [Accepted: 09/30/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score. METHODS A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated. RESULTS There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66. CONCLUSION The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.
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Affiliation(s)
- M Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - C H L Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - J Li
- Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - E Dixon
- Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - M Tun Abraham
- Hepatobiliary Surgery, Division of General Surgery, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - R Hernandez Alejandro
- Hepatobiliary Surgery, Division of General Surgery, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - S Bennett
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - P J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Karanicolas PJ, Lin Y, Tarshis J, Law CHL, Coburn NG, Hallet J, Nascimento B, Pawliszyn J, McCluskey SA. Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid. HPB (Oxford) 2016; 18:991-999. [PMID: 27765582 PMCID: PMC5144548 DOI: 10.1016/j.hpb.2016.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/19/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection. METHODS In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration. RESULTS No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA. CONCLUSIONS There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182.
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Affiliation(s)
- Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Calvin H L Law
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barto Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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Cuéllar-Guzmán LF, Pérez-González ÓR. Consideraciones perioperatorias en el paciente oncológico sometido a hepatectomía. GACETA MEXICANA DE ONCOLOGÍA 2016. [DOI: 10.1016/j.gamo.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Moggia E, Rouse B, Simillis C, Li T, Vaughan J, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev 2016; 10:CD010683. [PMID: 27797116 PMCID: PMC6472530 DOI: 10.1002/14651858.cd010683.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown. OBJECTIVES To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE. MAIN RESULTS We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work. AUTHORS' CONCLUSIONS Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.
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Affiliation(s)
- Elisabetta Moggia
- IRCCS Humanitas Research HospitalDepartment of General and Digestive SurgeryVia Manzoni 5620089 RozzanoMilanItalyItaly20089
| | - Benjamin Rouse
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Constantinos Simillis
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Tianjing Li
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Rekman J, Wherrett C, Bennett S, Gostimir M, Saeed S, Lemon K, Mimeault R, Balaa FK, Martel G. Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections. Surgery 2016; 161:650-657. [PMID: 27712877 DOI: 10.1016/j.surg.2016.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/22/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations. METHODS Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H2O). The target phlebotomy volume was 7-10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison. RESULTS A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3 cm H2O (0-15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications. CONCLUSION Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.
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Affiliation(s)
- Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Miso Gostimir
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sara Saeed
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Kristina Lemon
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Richard Mimeault
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
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Egger ME, Gottumukkala V, Wilks JA, Soliz J, Ilmer M, Vauthey JN, Conrad C. Anesthetic and operative considerations for laparoscopic liver resection. Surgery 2016; 161:1191-1202. [PMID: 27545995 DOI: 10.1016/j.surg.2016.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/06/2016] [Accepted: 07/09/2016] [Indexed: 02/06/2023]
Abstract
We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.
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Affiliation(s)
- Michael E Egger
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jonathan A Wilks
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthias Ilmer
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Schoettker P, Marcucci CE, Casso G, Heim C. Revisiting transfusion safety and alternatives to transfusion. Presse Med 2016; 45:e331-40. [DOI: 10.1016/j.lpm.2016.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Abstract
Operative blood loss is a major source of morbidity and even mortality for patients undergoing hepatic resection. This review discusses strategies to minimize blood loss and the utilization of allogeneic blood transfusion pertaining to oncologic hepatic surgery.
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Affiliation(s)
- Gareth Eeson
- Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room T2016, Toronto, ON M4N 3M5, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room T2016, Toronto, ON M4N 3M5, Canada.
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Zhou X, Zhang C, Wang Y, Yu L, Yan M. Preoperative Acute Normovolemic Hemodilution for Minimizing Allogeneic Blood Transfusion. Anesth Analg 2015; 121:1443-55. [DOI: 10.1213/ane.0000000000001010] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
For the 20% of patients with resectable colorectal liver metastases (CRLM), hepatic resection is safe, effective and potentially curative. Factors related to the primary and metastatic tumors individually and in clinical risk-scoring schemes are the best prognostic factors, although it is difficult to define patient groups with resectable, liver-limited CRLM that should be excluded from surgery. Systemic chemotherapy for metastatic colorectal cancer has improved but does not improve overall survival as adjuvant therapy after resection. Conversion to complete resection with systemic and/or hepatic arterial infusion chemotherapy is an appropriate goal for patients with unresectable CRLM.
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Wang HQ, Yang J, Yang JY, Wang WT, Yan LN. Development and validation of a predictive score for perioperative transfusion in patients with hepatocellular carcinoma undergoing liver resection. Hepatobiliary Pancreat Dis Int 2015; 14:394-400. [PMID: 26256084 DOI: 10.1016/s1499-3872(15)60362-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection is a major surgery requiring perioperative blood transfusion. Predicting the need for blood transfusion for patients undergoing liver resection is of great importance. The present study aimed to develop and validate a model for predicting transfusion requirement in HBV-related hepatocellular carcinoma patients undergoing liver resection. METHODS A total of 1543 consecutive liver resections were included in the study. Randomly selected sample set of 1080 cases (70% of the study cohort) were used to develop a predictive score for transfusion requirement and the remaining 30% (n=463) was used to validate the score. Based on the preoperative and predictable intraoperative parameters, logistic regression was used to identify risk factors and to create an integer score for the prediction of transfusion requirement. RESULTS Extrahepatic procedure, major liver resection, hemoglobin level and platelets count were identified as independent predictors for transfusion requirement by logistic regression analysis. A score system integrating these 4 factors was stratified into three groups which could predict the risk of transfusion, with a rate of 11.4%, 24.7% and 57.4% for low, moderate and high risk, respectively. The prediction model appeared accurate with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.736 in the development set and 0.709 in the validation set. CONCLUSIONS We have developed and validated an integer-based risk score to predict perioperative transfusion for patients undergoing liver resection in a high-volume surgical center. This score allows identifying patients at a high risk and may alter transfusion practices.
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Affiliation(s)
- Hai-Qing Wang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.
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Mudge MC. Options for reducing allogeneic blood transfusions. EQUINE VET EDUC 2015. [DOI: 10.1111/eve.12325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M. C. Mudge
- Department of Veterinary Clinical Sciences; The Ohio State University; Columbus USA
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Fluid Restriction During Pancreaticoduodenectomy: Is It Effective in Reducing Postoperative Complications? Adv Surg 2015; 49:205-20. [PMID: 26299500 DOI: 10.1016/j.yasu.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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