Current practices in perioperative blood management for patients undergoing liver resection: a survey of surgeons and anesthesiologists

Abstract

Objective: Trans-arterial chemoembolization (TACE) is the recommended treatment for intermediate-stage hepatocellular carcinoma (HCC) according to American Association for the Study of Liver Disease (AASLD) guidelines. In an era of healthcare regionalization, it is unclear whether hospital volume is associated with post-TACE outcomes. Methods: The 2012 linkage of Surveillance, Epidemiology, and End Results (SEER)-Medicare database was utilized. A multivariable Cox proportional hazards model was utilized to evaluate the association between post-TACE survival and patient factors, hospital characteristics, and TACE volume. Results: 4258 patients with HCC treated with TACE comprised the study cohort. The mean age was 70, patients were 69.7% male, 60.6% Caucasian, 58.8% had HCV, 40.0% had multifocal disease, and median tumor size was 4.5 cm. Teaching hospitals, large hospitals and hospital performing >100 TACE treated 59.0%, 47.5%, and 35.8% of patients respectively. Median survival was 24.5 months. Unadjusted KM survival analysis demonstrated improved survival in hospitals performing >100 TACE annually (p < 0.001, figure). After controlling for sociodemographic, oncologic, and hospital characteristics, there was no significant association with TACE volume and survival. Significant survival predictors were household income, HBV status, extrahepatic disease, Charlson score, tumor size, AJCC stage, concordance with AASLD guidelines, and receiving additional oncologic treatments. Conclusion: Neither hospital size, teaching status, nor TACE volume predicted survival in the Medicare patient population. These data encourage widespread utilization of TACE.

A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Intraoperative Red Blood Cell Transfusion Strategies

“…First, despite a majority of anesthesiologists identifying hemoglobin concentration as the most important factor when deciding on an intraoperative transfusion, it may be less relevant to guide RBC transfusion in the setting of active or rapid blood loss, particularly given the significant variation in hemoglobin concentration with volume of administered crystalloid or colloid fluids. 23 Second, hemodynamic variations in surgical patients are not necessarily reflective of anemia from surgical bleeding, and may result from other factors such as pharmacologic anesthetic agents, patient positioning, mechanical ventilation, neuraxial analgesia, surgical manipulation, and abdominal insufflation. 24 , 25 A comprehensive synthesis of randomized trials comparing intraoperative transfusion strategies does not exist, and is thus timely and necessary.…”

Patient perspectives on intraoperative blood transfusion: A qualitative interview study with perioperative patients

“…30 A unique finding was that despite anaesthesiologists frequently initiating intraoperative transfusion, patients almost exclusively referenced their surgeons when discussing transfusion. 31 This is likely explained by the brief nature of the anaesthesiologist-patient relationship, transfusion consent being obtained by the surgical team, and disclosure of intraoperative transfusions by the surgeon. This dynamic means that any preference related to intraoperative transfusion expressed to the surgeon during preoperative consent discussions must be communicated to the anaesthesiologist for it to be considered when making intraoperative transfusion decisions.…”

“…A unique finding was that despite anaesthesiologists frequently initiating intraoperative transfusion, patients almost exclusively referenced their surgeons when discussing transfusion 31 . This is likely explained by the brief nature of the anaesthesiologist‐patient relationship, transfusion consent being obtained by the surgical team, and disclosure of intraoperative transfusions by the surgeon.…”