Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections

Rekman, Janelle; Wherrett, Christopher; Bennett, Sean; Gostimir, Mišo; Saeed, Sara; Lemon, Kristina; Mimeault, Richard; Balaa, Fady; Martel, Guillaume

doi:10.1016/j.surg.2016.08.026

Cited by 14 publications

(30 citation statements)

References 26 publications

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“…This work relies on a systematic process with literature review, analysis of practice, and focus group establishing priorities, followed by a modified Delphi approach. 8,24,25,30,33,42,49 The Delphi methodology was used to obtain consensus in an area where the literature may be imperfect. [20][21][22] The panelists were representative of experts in the fields of HPB surgery, anesthesiology and transfusion medicine, from across Canada, and practicing in various settings.…”

Section: Discussionmentioning

confidence: 99%

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Patient blood management for liver resection: consensus statements using Delphi methodology

Hallet

Jayaraman

Martel

et al. 2019

HPB

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Background: Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. Methods: An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. Results: The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. Conclusions: PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

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Section: Discussionmentioning

confidence: 99%

“…It was acknowledged that some teams have used this approach successfully. 30 However, the evidence is limited to retrospective cohort studies with small sample sizes. Therefore, in the absence of strong evidence to support benefits of hypovolemic phlebotomy, the panel cannot recommend for or against its routine use for LR.…”

Section: Intra-operative Carementioning

confidence: 99%

Patient blood management for liver resection: consensus statements using Delphi methodology

Hallet

Jayaraman

Martel

et al. 2019

HPB

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“…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.…”

Section: Methodsmentioning

confidence: 99%

“…Intraoperative hypovolaemic phlebotomy (HP) is one such technique, which is relatively novel and understudied. HP involves the removal of 7–10 ml per kg whole blood without intravenous volume replacement. This approach is thought to lead to a state of relative hypovolaemia, comparable to class 1 haemorrhage.…”

Section: Introductionmentioning

confidence: 99%

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

Martel

Baker

Wherrett

et al. 2020

British Journal of Surgery

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Background: Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial.Methods: Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL).Results: A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3⋅1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was −111 ml (P = 0⋅456). Among patients at high risk of transfusion, the median EBL difference was −448 ml (P = 0⋅069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7⋅6(1⋅9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0⋅326).Conclusion: Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 (http://www.clinicaltrials.gov).

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“…low central venous pressure, phlebotomy with controlled hypovolemia), and liver inflow occlusion. 12,[16][17][18][19][20] Incorporating such strategies into clinical practice relies on predicting patient risk of transfusion preoperatively to direct appropriate strategies at patients likely to benefit while optimizing use of resources.…”

Section: Introductionmentioning

confidence: 99%

Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP)

Lemke

Mahar

Karanicolas

et al. 2018

HPB

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Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections

Cited by 14 publications

References 26 publications

Patient blood management for liver resection: consensus statements using Delphi methodology

Patient blood management for liver resection: consensus statements using Delphi methodology

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

Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP)

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