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Correspondence |
Hôpital St-Luc, CHUM, Montréal, Canada, E-mail: lmassicotte{at}hotmail.com
To the Editor:
We wish to suggest a technique for reducing red blood cell (RBC) transfusions during liver transplantation. Previously, correction of coagulation defects with plasma transfusions did not decrease the need for intraoperative RBC transfusion during liver transplantations.1 On the contrary it had produced a hypervolemic state that resulted in an increase of shed blood. As well, plasma and RBC transfusions have been associated with a decreased one-year survival rate.2–4 The aim of the present prospective survey was to evaluate whether anesthesiologists could reduce intraoperative RBC transfusions during liver transplantation by changing their anesthesia practice, more specifically by maintaining a low central venous pressure (CVP), by restricting volume replacement, by eliminating all plasma transfusions and by using intraoperative phlebotomy during the transplantation.
With the approval of our hospital Ethics Committee, 61 liver transplantations were prospectively studied during a one-year period and were compared to a retrospective series (1998–2002).1 A low CVP was maintained in all patients prior to the anhepatic phase. Coagulation disorders were not corrected. Phlebotomy and cell savers (CS) were used following pre-established criteria (Hb 
85 g·L–1, normal renal function, hemodynamic stability and enough potential blood loss to prime the CS). The purpose of the phlebotomy at the beginning of the case was to reduce the CVP. Hemodilution was not used, which also avoided coagulation factor dilutions.
The mean number of intraoperative RBC units transfused per patient was 0.3 ± 0.7. No plasma, nor platelets, nor cryoprecipitate were transfused. Seventy-nine percent of the patients received no blood products during their liver transplantation. The CVP was lowered significantly from an average of 12.0 ± 3.9 mmHg at the beginning of the procedure to an average of 8.1 ± 4.2 mmHg. In 28 patients (45.9%), intra-operative phlebotomy and CS were used either together or separately. The median for transfusion of all blood products for the 72 hr postoperatively was zero. There were neither cardiac complications nor any neurological complications. There was no intraoperative death nor any death in the 30-day period postoperatively. The one-year survival rate was 91.4%.
The avoidance of plasma transfusion was associated with a decrease in RBC transfusion during liver transplantation. Previous reports5 indicating that it is neither useful nor necessary to correct coagulation defects with plasma transfusions prior to liver transplantation are further corroborated by this prospective survey. Our data indicate that this novel practice does not result in any deleterious effect.
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1 Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg 2004; 98: 1245–51.
2 Cacciarelli TV, Keeffe EB, Moore DH, et al. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg 1999; 134: 25–9.
3 Ramos E, Dalmau A, Sabate A, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl 2003; 9: 1320–7.[Medline]
4 Massicotte L, Sassine MP, Lenis S, Seal RF, Roy A. Survival rate changes with transfusion of blood products during liver transplantation. Can J Anesth 2005; 52: 148–55.
5 Reyle-Hahn M, Rossaint R. Coagulation techniques are not important in directing blood product transfusion during liver transplantation. Liver Transpl Surg 1997; 6: 659–63.
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