Hypovolemic phlebotomy in liver surgery is associated with decreased red blood cell transfusion

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)(2011)(2012)(2013)(2014)(2015)(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 H 2 O). 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.

Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility

“…–422 to 75) ml) and RBC transfusion (odds ratio 0·25, 95 per cent c.i. 0·07 to 0·87), and safe in comparison to standard care. Putchakayala and DiFronzo documented the largest decrease in EBL with HP (mean 480 versus 904 ml; P < 0·001) in a study reporting on safety and feasibility in patients with medical co‐morbidities.…”

“…The study has limitations, including that it was powered partly to determine whether HP is protective of EBL, but may have been underpowered to demonstrate an association based on these data alone. The sample size calculation was generated from observational data relying on visual estimates by surgeons and anaesthetists, where the same procedural rigour was not implemented to estimate blood loss. It is worth mentioning that EBL estimates reliant on measuring fluid in suction canisters often take into account the quantity of irrigation fluid.…”

“…Seven other studies reporting on the use of HP in liver surgery were identified in a systematic review, including two RCTs, four retrospective cohort studies of patients undergoing liver resection (3) or liver transplantation (1), and one case series of patients undergoing liver resection. Pooled analysis of studies reporting on patients undergoing HP versus standard of care at the time of liver resection for non‐transplant indications reported that HP was protective of blood loss (–173 (95 per cent c.i.…”

“…A designated group of anaesthetists was involved in PRICE‐1. All anaesthetists had received training in the trial protocol and standard operating procedures, and had previous experience of HP.…”

“…Observational studies in liver resection are encouraging, and demonstrated an association with decreased blood transfusion (odds ratio 0·20, 95 per cent c.i. 0·07 to 0·57). It should be noted that HP is distinct from acute normovolaemic haemodilution.…”