Evaluation of cell salvage autotransfusion utility during liver transplantation

Massicotte, Luc; Thibeault, Lynda; Beaulieu, Danielle; Roy, Jean‐Philippe; Roy, André

doi:10.1080/13651820601090596

Cited by 43 publications

(67 citation statements)

References 22 publications

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“…practice in different institutions [117] . Obviating the need for at least 2 units of allogenic RBC delivers a cost-benefit and therefore ACS is likely to be financially viable in major blood loss surgery where transfusion is expected.…”

Section: Donohue CI Et Al Reducing Transfusion Requirements In Livementioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusionfree transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical "piggyback" techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT. Core tip: Liver transplantation (LT) was historically associated with massive blood loss. Many factors have contributed to the decline in bleeding and transfusion in the past two decades including refinement of surgical techniques, anaesthetic management and the use of point of care guided goal-directed haemostatic therapies. Increasing awareness of the adverse associations of allogenic transfusion has driven the quest for transfusion-free transplantation. Increasing use of marginal grafts and transplantation of sicker recipients will continue to challenge perioperative care and transfusion practice. Inter-institutional variability suggests a current lack of clear guidance and limited application of the principles of patient blood management to LT.

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Section: Donohue CI Et Al Reducing Transfusion Requirements In Livementioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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“…Muscari et al [117] reported no difference in the incidence of neoplastic recurrence with the use of cell saver during liver transplantation for hepatocarcinoma. Various authors also confirm that the use of cell salvage is useful to reduce the exposure to allogenic blood during liver transplantation for hepatocellular carcinoma and is cost-effective as well [95,115] . Filtration through leucodepletion filters in association with irradiation (25 Gy) prior to transfusion of recovered blood has also been proposed to increase the safety of blood salvaging procedure in cancer surgery [118] .…”

Section: Blood Salvaged From Patients With Liver Tumormentioning

confidence: 99%

“…However, when compared with the cost of providing allogenic blood, it becomes cost effective when at least two or more units of blood can be salvaged and reinfused. Massicotte et al [95] demonstrated that when cell salvage autotransfusion was used systematically for every patient (75 OLTx) there was enough blood salvage to retransfuse 65% of the cases; in their centre with a low transfusion rate, it saved a mean of 21 g/L of Hb per patient or two RBC unit transfusions.…”

Section: Blood Salvage During Oltxmentioning

confidence: 99%

“…The resultant hematocrit ranges between 50%-80% [15] . Although the safety of cell-salvaging procedure has been widely demonstrated [94] intraoperative red blood cell salvage and autologous transfusion is not routinely used in major liver surgery as cost-effectiveness is still an unsolved concern [95] . Blood salvaging techniques are controversial during OLTx as well, since some studies demonstrated their effectiveness in reducing allogeneic RBCs requirements and safety, while others reported higher blood loss, mainly through fibrinolysis, and increased costs [7,96,97] .…”

Section: Blood Salvage During Oltxmentioning

confidence: 99%

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Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation

Feltracco¹

2013

WJH

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Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system, portal hypertension with multiple collateral vessels, portal vein thrombosis, previous abdominal surgery, splenomegaly, and poor "functional" recovery of the new liver. The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge, and, despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss, the requirements for blood or blood products remains high. The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome. Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated. Isovolemic hemodilution, the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion. The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications. In this article we report on the common preoperative and intraoperative factors contributing to blood loss, intraoperative transfusion practices, anesthesiologic and surgical strategies to prevent blood loss, and on intraoperative blood salvaging techniques and autologous blood transfusion. Even though the advances in surgical technique and anesthetic management, as well as a better understanding of the risk factors, have resulted in a steady decrease in intraoperative bleeding, most patients still bleed extensively. Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center. Unfortunately, despite the large number of OLTx performed each year, there is still paucity of large randomized, multicentre, and controlled studies which indicate how to prevent bleeding, the transfusion needs and thresholds, and the "evidence based" perioperative strategies to reduce the amount of transfusion.

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“…Another important surgical measure to reduce perioperative blood product transfusions is use of intraoperative cell salvage (CS). In a prospective survey conducted by Massicotte et al [43] in patients undergoing LT, the use of CS was associated with saving two RBCs unit transfusions per patient and thus also reducing costs. Nowadays, however, as an increasing amount of transfusion-free LTs are performed, a "stand by" set up rather than routine application of CS is recommended [34].…”

Section: Non-pharmacological Interventionsmentioning

confidence: 99%

Perioperative bleeding in patients undergoing liver transplantation

Starczewska

Giercuszkiewicz²,

Niewiński³

et al. 2016

Anaesthesiol Intensive Ther

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Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years, significant progress in surgical technique and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patient's mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipients outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during recipients have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.Key words: liver transplantation, perioperative management, haemostasis, bleeding Anaesthesiology Intensive Therapy 2016, vol. 48, no 1, 34-40 Liver transplantation (LT) remains one of the most challenging surgical technique. For many years, uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During more than the fifty years of experience gained since the first LT was performed by Thomas Starzl in 1963, an improvement in surgical techniques and anaesthetic management has led to a marked change in transfusion practices over time. A recently published retrospective analysis of data from the Mayo Clinic in Rochester has shown that over the last two decades there has been a significant decrease in the amount of perioperatively transfused red blood cells (RBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate and intraoperative autotransfusions [1]. Interestingly, this was noted despite the fact that transfusion triggers remained the same over time [1]. Massicotte et al. [2] reported that currently up to 79.6% of LTs are performed without any blood product transfusion. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in management of haemostasis in LT recipients. HAEMOSTATIC ALTERATIONS IN LIVER TRANSPLANT RECIPIENTSThe change in transfusion practices was possible due to a better understanding of alterations in the haemostatic system in LT recipients. The l...

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Evaluation of cell salvage autotransfusion utility during liver transplantation

Abstract: Despite increased blood loss in period 2, CS saved 21 g/L of Hb per patient or two RBC unit transfusions. As long as we cannot predict with accuracy which patients will bleed, we will continue to use the CS for all OLTs.

Cited by 43 publications

References 22 publications

Reducing transfusion requirements in liver transplantation

Reducing transfusion requirements in liver transplantation

Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation

Perioperative bleeding in patients undergoing liver transplantation

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