Controlling bleeding during liver resection

AORN Journal,  Sept, 2007  by George Allen

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Annals of Surgery

May 2007

Controlling bleeding during liver resection is an ongoing battle. The main source of bleeding during this procedure is the hepatic veins and their tributaries. Consequently, reduction of central venous pressure (CVP) has been employed successfully to reduce intraoperative blood loss. Methods such as the administration of vasodilators, reduction of respiratory tidal volume, restriction of IV fluid infusion, and clamping of the infrahepatic vena cava all have been used to reduce CVP. A consistently effective and safe method to obtain the desired reduction of CVP to reduce intraoperative blood loss, however, has not yet been established.

As a preliminary investigation, the authors of this study examined the effect of collecting a modest amount of blood as blood salvage after initiation of liver transection and observed a decrease in intratransectional bleeding. They hypothesized that blood salvage before initiation of hepatic parenchymal division would reduce intratransectional blood loss. The purpose of this randomized, controlled trial was to test this hypothesis.

All donors scheduled to undergo liver graft procurement for elective living donor liver transplantation at the Tokyo University Hospital, Japan, were considered as potential participants. Inclusion criteria were acceptable general condition of the liver donor candidate and age between 18 and 65 years. Patients were excluded if they had

* hypertension or hypotension,

* hemoglobin levels less than 11 g/dL within a week before surgery,

* a prothrombin time international normalization ratio greater than 1.5,

* a bleeding time greater than five minutes, or

* unstable hemodynamics during surgery.

In the OR, participants were randomly assigned to either the blood salvage group (n = 40 patients) or a control group (n = 39 patients). For patients in the blood salvage group, a blood volume equal to approximately 0.7% of the patient's body weight was collected before the liver transection and rein fused into the patient after the graft was procured; patients in the control group did not undergo blood salvage. Intraoperatively, patients'

* continuous invasive arterial pressure,

* heart rate,

* electrocardiographic values,

* CVP,

* pulse oximetry,

* end-tidal carbon dioxide tension, and

* rectal temperature were monitored.

The primary outcome measure was blood loss during hepatic parenchymal division. Secondary outcome measures included

* total blood loss,

* blood loss during hepatic parenchymal division per unit of transectional area,

* CVP at the start of hepatic parenchymal division,

* serum aspartate aminotransferase and total bilirubin levels on the third postoperative day,

* length of hospital stay, and

* morbidity.

Common statistical procedures, including the Fisher exact test, the Wilcoxon rank sum test, and logistic regression techniques, were used to analyze differences between the groups.

FINDINGS. The median amount of intraoperative blood salvage among the 40 donors in the blood donor salvage group was 420 g (range 260 g to 620 g). Blood loss during hepatic parenchymal division was significantly lower in the blood salvage group than in the control group (median 140 mL, range 40 mL to 430 mL versus 230 mL, range 40 mL to 660 mL, respectively; P = .034). Additionally, blood loss per unit transactional area during hepatic parenchymal division was significantly lower in the blood salvage group than in the control group (2.15 mL/[cm.sup.2], range 0.86 mL/[cm.sup.2] to 7.37 mL/[cm.sup.2] versus 3.75 mL/[cm.sup.2], range 0.64 mL/[cm.sup.2] to 7.93 mL/[cm.sup.2], respectively; P = .012). The CVP at the beginning of the hepatic parenchymal division was significantly lower in the blood salvage group than in the control group (median 5 cm [H.sub.2]O versus 6 cm [H.sub.2]O, P = .005). The multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during hepatic parenchymal division (adjusted odds ratio 0.31; 95% confidence interval 0.11-0.85, P = .025).

CLINICAL IMPLICATIONS. The results of this study revealed that modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal division. Perioperative nurses should become familiar with the procedures and techniques required for safely salvaging blood during these surgical procedures.

Hashimoto T, Kokudo N, Orii R, et al. Intraoperative blood salvage during liver resection: a randomized controlled trial. Ann Surg. 2007;245(5):686-691.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

COPYRIGHT 2007 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning