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Blood product use during orthotopic liver transplantation

Montreal, Quebec

To the Editor:

Although orthotopic liver transplantation (OLT) has traditionally been associated with transfusion of considerable quantities of blood products, this has been challenged recently.^1–3 The present study evaluates blood product use during OLT at our hospital.

Following Ethics Board approval, data were analyzed from 218 consecutive first-time OLT (1995–2000). Anesthesia and surgery were performed using standard techniques.⁴ Venovenous bypass and the piggyback technique were never employed. All patients received aprotinin (500,000–2,000,000 U bolus followed by 500,000 U•hr^–1). Intraoperative blood testing was minimized (1 mL samples for blood gas, hematocrit and electrolyte determination). Coagulation analysis (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR], fibrinogen level, platelet count) was done only if clinically indicated (excessive oozing, lack of clots). In the absence of neoplasm, scavenged blood was returned to the patient using a cell saver. Transfusion triggers for packed red blood cells (PRBC) included hematocrit less than 0.25 or sudden catastrophic blood loss. Platelets, cryoprecipitate, and fresh frozen plasma (FFP) were transfused on the clinical impression of "medical" bleeding. Predetermined transfusion triggers were not used. Patients were divided into Group I (no blood products used) and Group II (blood products used).

Of the 218 OLT, no blood products were given intraoperatively in 35 (16%) patients (Group I). Blood products were given to 183 patients in Group II (PRBC: 3.9 ± 2.8; FFP: 5.6 ± 4.1; platelets: 4.8 ± 7.6 and cryoprecipitate: 3.3 ± 5.6). Group I patients had a lower preoperative INR, PT, PTT, total bilirubin, ASA status, MELD score, Child-Pugh score, Canadian liver transplant status and they had a higher preoperative hemoglobin and albumin (Table). Groups I and II had a similar postoperative hematocrit (0.33 ± 0.04 and 0.31 ± 0.06, respectively), INR (2.3 ± 1.2 and 2.9 ± 2.5, respectively), PT (18.8 ± 5.2 and 20.6 ± 8.4, respectively), and PTT (74.9 ± 27.2 and 84.7 ± 36.1, respectively). However, Group 1 demonstrated a higher postoperative platelet count (124.8 ± 49.9 vs 92.8 ± 46.7, P < 0.0004). The only independent variable significantly associated with absence of any blood product transfusion was the Child-Pugh score (P = 0.019, odds ratio = 0.7, 95% confidence interval = 0.52–0.94). The MELD score (P = 0.087) and preoperative hemoglobin (P = 0.077) just failed to achieve statistical significance.

References

1 Marcel RJ, Stegall WC, Suit CT, et al. Continuous small-dose aprotinin controls fibrinolysis during orthotopic liver transplantation. Anesth Analg 1996; 82: 1122–5.[Abstract]

2 Cacciarelli TV, Keeffe EB, Moore DH, et al. Primary liver transplantation without transfusion of red blood cells. Surgery 1996; 120: 698–704.[Medline]

3 Ramos E, Dalmau A, Sabate A, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction requirements, and measures to reduce them. Liver Transpl 2003; 9: 1320–7.[Medline]

4 Baldry C, Backman SB, Metrakos, P, Tchervenkov J, Barkun J, Moore, A. Liver transplantation in a Jehovah’s Witness with ankylosing spondylitis. Can J Anesth 2000, 47: 642–6.[Abstract/Free Full Text]

5 Reyle-Hahn M, Rossaint R. Coagulation techniques are not important in directing blood product tansfusion during liver transplantation. Liver Transpl Surg 1997; 6: 659–63.

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