Transfusions of packed red blood cells in surgery for liver cancer: predictor of impaired overall survival but not recurrence-free survival - impact of blood transfusions in liver surgery

BACKGROUND

Liver surgery remains a cornerstone of potentially curative multimodal treatments for primary malignancies of the liver and hepatic metastases. Improving perioperative safety is a prerequisite in this context. Perioperative blood transfusions negatively influence postoperative recovery. This study aimed to identify risk factors for perioperative packed red blood cell (PRBC) transfusion and to elucidate its effect on postoperative outcomes.

METHODS

This was an observational study of a prospective data collection. A monocentric, retrospective analysis of 1118 hepatectomies at the University Hospital Carl Gustav Carus between 2013 and 2020 was conducted to compare postoperative short- and long-term outcomes in patients undergoing curative intended liver resection of hepatic primary or secondary malignancies. The outcomes were compared between 356 patients (31.8%) who received PRBC transfusions during surgery or within 7 days after surgery and 762 patients (68.2%) who did not receive PRBC transfusions.

RESULTS

Preoperative anemia could be observed in 45.0% of the whole cohort: 65.7% in the PRBC transfusion group and 35.3% in the nontransfused group. Postoperative complications were significantly more common in the PRBC transfusion group in association with prolonged lengths of hospital stay and increased 30-day mortality than in the nontransfused group. After adjustment for possible confounders, preexisting kidney failure, preoperative hemoglobin and albumin levels outside of the reference range, intraoperative plasma transfusions, and overall surgery time were recognized as negative predictors for perioperative PRBC transfusions. PRBC transfusion increased the risk of death by approximately 38.8% (hazard ratio, 1.388; 95% CI, 1.027-1.876; P = .033), whereas no influence on recurrence-free survival (RFS) was observed.

CONCLUSION

PRBC transfusions were associated with postoperative morbidity and mortality after curative-intended surgery for liver cancers and represented an independent poor prognostic indicator for overall survival but not for RFS.

Regional tissue oxygenation and conventional indicators of red blood cell transfusion in anaemic preterm infants

BACKGROUND

It is unresolved whether low haemoglobin (Hb) and symptoms of anaemia reflect oxygen delivery-consumption imbalances (fractional tissue oxygen extraction [FTOE]). Here, we test whether pre-transfusion Hb and symptoms of anaemia correlate with pre-transfusion cerebral and splanchnic FTOE.

METHODS

This prospective cohort study was carried out between Sept 1, 2014 and Nov 30, 2016 at Nepean Hospital, Sydney, Australia. The study enroled haemodynamically stable preterm infants: gestation <32 weeks; birth weight <1500 gs; postmenstrual age <37weeks, who received 15 mL/kg packed red blood cell transfusion (PRBCT) based on low Hb and symptoms of anaemia. FTOE was determined using simultaneous monitoring of near-infrared spectroscopy and pulse oximetry for 4 h before PRBCT.

FINDINGS

The study enroled 29 infants born with a median gestation of 26.4 weeks (IQR 25.4-28.1), birth weight 922 g (655-1064), at postmenstrual age 33.6 weeks (31.7-34.9), and weight 1487 g (1110-1785). There was no significant correlation between Hb (median 97 g/L, IQR 87-100) and cerebral FTOE (r=-0.12, 95% CI -0.47 to 0.27; p = 0.54, n = 29) as well as splanchnic FTOE (r=-0.09, 95% CI -0.45 to 0.29; p = 0.64, n = 29). Median cerebral FTOE (p = 0.67) and splanchnic FTOE (p = 0.53) did not differ between symptomatic and asymptomatic groups.

INTERPRETATION

Our preliminary findings suggest that pre-transfusion Hb and symptoms of anaemia might not accurately reflect oxygen delivery-consumption imbalances in both the brain and the gut. A lack of correlation with cerebral FTOE might be presumed to be due to the brain-sparing effect. However, the lack of correlation with splanchnic FTOE is more concerning. Hence, these results warrant larger studies incorporating FTOE along with the conventional criteria in the transfusion algorithm.

FUNDING

The study was funded (for the purchase of NIRS sensors) by the Australian Women and Children's Research Foundation.