Changes of anesthesia protocols

aiming to reduce blood loss

during major liver resections
E. Odisseeva
 The Goals of Anesthesia in 2000’s

• Patient Safety

• Surgeon Comfort

• Promotion of accelerated recovery

 The Goals of Anesthesia in 2000’s

• Patient Safety

• Surgeon Comfort

• Promotion of accelerated recovery

Anesthesia for LR - very specific process

 i o n
f us
n s
tr a ?
m o l e m
ae r o b
s H P
I a

Transfusion Medicine Copyright (c) 2007-2009, Pathology Outlines.coм / Last revised 19 January 2009 / Last major update August 2007
 In Liver Surgery …….
TACO
(Тransfusion Related Cardiac Overload )

 Inevitable in any transfusion of FFP or RBC

 The increase of plasma volume leads to bleeding
difficult to control
 In the condition of liver mass reduction:
 Residual liver parenchyma congestion
 Liver ischemia due to portal hypertension and hepatic
arterial vasoconstriction due to HABR
 In Liver Surgery…….
 TRALI – ( Transfusion Related Lung Injury )

 Dilution coagulopathy – massive transfusion

 TRIM – (Transfusion Related Immune Modulation)

 Effect is associated with every unit blood product transfused

 TRIM may increase nosocomial infections rate

 Delayed wounds healing

 Sepsis

 Immunosuppression is detrimental for tumor surveillance

 Avoiding Transfusions:
Is This Important?
 Non transfused pts had fewer complications
than those receiving blood
(33% vs 46%, P<.0001)

 Receiving 1-2 units had fewer complications

than those receiving > 2units
(42% vs 51%, P=.03)

Kooby D. Ann Surg 2003; 237: 860

 Effect of Intraoperative Blood Transfusion
on Patient Outcome in Hepatic Transplantation
Thomas V. Cacciarelli, MD; Emmet B. Keeffe, MD; Dan H. Moore, PhD; Washington Burns, MD;
Stephan Busque, MD; Waldo Concepcion, MD; Samuel K. S. So, MD; Carlos O. Esquivel, MD, PhD
From Liver International
Morbidity and Mortality After Liver Resection for Benign
and Malignant Hepatobiliary Lesions
DehaErdogan; Olivier R.C. Busch; Dirk J. Gouma; Thomas M. van Gulik
Published: 04/02/2009
Increased Mortality, Postoperative Morbidity, and Cost
After Red Blood Cell Transfusion in Patients Having
Cardiac Surgery
Gavin J. Murphy, BSc, ChB, MD, FRCS(CTh); and al .
Circulation 2007;116;2544-2552; published online Nov 12, 2007;

Survival rate changes with transfusion of blood products during liver transplantation [Le taux de survie change avec la
transfusion de produits sanguins pendant la transplantation hépatique]
Luc Massicotte MD, et al CAN J ANESTH 2005 / 52: 2 / pp 148–155
 Institutional Variability in Transfusion Practice for Liver Transplantation
Yves Ozier, MD*, FabiennePessione, MD†, Emmanuel Samain, MD‡, and Francoise Courtois, MD§, for the French Study
Group on Blood Transfusion in Liver Transplantation *
ANESTH ANALG 2003;97:671–9

Visgeral organ resections combined with synchronous major hepatectomy :

examples of safety and feasibility
RE Schwarz Division of Surgical Oncology, Cancer Institute of New Jersey
HPB 2003 Volume 5, number I 27-32

Morbidity of Major Hepatic Resections: a 100-Case Prospective Study

Bernard Pol, Pierre Campan, Jean Hardwigsen, Genevie`veBotti,Julien Pons and Y. Patrice Le Treut
From the Department of Surgery, Hoˆpital de la Conception and Department of Medical Information,
Hoˆpital de la Timone, Marseille, France
Eur J Surg 1999; 165: 446–453

One Thousand Fifty-Six Hepatectomies Without Mortality in 8 Years

Hiroshi Imamura, MD, PhD; Yasuji Seyama, MD; NorihiroKokudo, MD, PhD; Atsushi Maema, MD, PhD;
Yasuhiko Sugawara, MD, PhD; Keiji Sano, MD, PhD; TadatoshiTakayama, MD, PhD; Masatoshi Makuuchi,
MD, PhD Arch Surg. 2003;138:1198-1206

Impact of Blood Loss on Outcome after Liver Resection.

de Boer, Marieke T; Molenaar, I. Quintus ; Porte, Robert J.
Digestive Surgery; 2007, Vol. 24 Issue 4, p259-264, 6p
 THBF
(~100 mL/min/100 g liver
mass)
Surgical strategy to reduce blood loss
Inflow control - Hilus occlusion
Hemodynamic effects
•Systemic arterial pressure
10%
•Systemic vascular resistance
40%
•Cardiac index 10%
•Release of clamp leads to
decrease in blood pressure that
returns to normal in a few
minutes
Outflow control -
TVE
Hemodynamic Effect of TVE
Traité d’anesthésie générale A mises à jour périodiques Bernard DALENS 2001
 Limitations
• Limitation of surgical time – 60:90 min

• Hemodynamic effects
• Bowel edema, smaller operating field with limited
surgical exposure and difficult closure

• Warm ischemia

• Reperfusion syndrome

• Failure of Hilus Clamping to Control Bleeding

Anesthesiologic strategy
Anesthesiologic strategy
 Intraoperative Monitoring
 Circulation :
NIBP, IBP, CVP, diuresis

 Ventilation:
MV, TV, Paw, PEEP,
PeCO2, SpO2
Anesthesiologic strategy
 The reasons for hypotension
• Reduction of venous return and CO by:
– Manipulation in the liver hilus
– IVC, v.portae and v. hepatics clampaging
– Direct VCI compression
• Loss of intravascular volume
– Bleeding
– Vaporization from the surgical field
• Air embolism
How we can manage hypotension
• Volume replacement
– Cristaloid
– Coloid
– Blood and blood products
• Vasoconstrictors
– Noradrenalin
– Dopamin
Anesthesiologic strategy
 Fluids: is caution required?
Massicote L. Liver transplantation 2006 ; 117-123

• Low hydrostatic pressure during LR is

associated with decreased blood loss
• Hemodilution
– Reduce hematocrit
– Trigger RBC transfusion
– Decreases Plt efficacy
– Dilute and/or alter physiological balance of
coagulation factors
 Complications of Crystalloid Fluid
Resuscitation
 Hypothermia
  calcium,  magnesium (Dilutional)
 Coagulopathy
─ Dilutional
─ Consumptive
─ Hypothermia
─ Hypocalcemia
 Edema
 Acidosis - non-anion gap
metabolic acidosis
─ Confusion with anion gap metabolic acidosis
─ Check chloride
 Complications of Crystalloid Fluid
Resuscitation
 Hypothermia
  calcium,  magnesium (Dilutional)
 Coagulopathy
─ Dilutional
─ Consumptive
─ Hypothermia
─ Hypocalcemia
 Edema
 Acidosis - non-anion gap
metabolic acidosis
─ Confusion with anion gap metabolic acidosis
─ Check chloride
 Complications of Crystalloid Fluid
Resuscitation
 Hypothermia
  calcium,  magnesium (Dilutional)
 Coagulopathy
─ Dilutional
─ Consumptive
─ Hypothermia
─ Hypocalcemia
 Edema
 Acidosis - non-anion gap
metabolic acidosis
─ Confusion with anion gap metabolic acidosis
─ Check chloride
 Complications of Colloid
Resuscitation

• Fluid overload
• Coagulopathy
– Dilution
– Direct  factor VIII
– theoretically after 2L
• Platelet aggregation problems
Anesthesiologic strategy
 Transfusion trigger

• In case of massive hemorrhage >30% of BV

• Hemorrhage without surgical control

• Hb < 70 g/l

• Ht < 0.22

• Exception for pts with CAD - Hb > 90 g/l

Anesthesiologic strategy
 Low CVP < 6 mmHg
 M.Johnson ; R.Mannar1998
 Liverpool UK
6 – 12
CVP > 12 mmHg
CVP < 6 mmHg mmHg

303 ml 1259 ml 2703 ml

↑2 x CVР ↑9 x Blood loss

Anesthesiologic strategy
Temperature monitoring and control
 July 2004 - December 2009
Military Medical Academy
Clinic of Hepatobiliary, Pancreatic and
Transplant Surgery
 130 patients
 High volume liver resection – > 3
segments
 Factors contributing hemorrhage
 Study Design
 Сut-point - blood loss > 500 ml
o Group 1 - blood loss < 500 ml
o Group 2 - blood loss > 500 ml

 Infusion therapy protocol

o 2004 – 2007 - liberal strategy
o 2008 – 2009 - restrictive strategy
 The groups are Statistically Comparable
N of pts Blood Sex Age НСС Meta СА- Benign % Cancer
loss М/F (average) CRC others

77 < 500 40 / 37 58,2 11 51 12 3 96 %

53 > 500 25 / 29 57,1 14 32 6 1 98,1%

<500 ml >500 ml Total

Period 2004 - 2007 27 43 70

Period 2008 - 2009 50 10 60

Total 77 53 130
 Group 1 Group 2
Operation N segments
< 500 ml > 500 ml
HHD
3 31 33

HLD
4 4 4

HHS 3 16 7

Meso H
3 6 2
HLS + Sg + MetA
> 3 сегм. 17 5

Sg resection > 3 сегм. 3 2

Total 77 53
N of Pts Compared to Periods
80
70
60
10
50 43
40 Blood loss <500
30 Blood loss >500
50
20
27
10
0
2 0 04-2007 2 0 08 -2009
 Pourcentage
80
70
60
17 %
50 62%
40 Blood loss>500
30 Blood loss<500
83%
20
38%
10
0
2 0 04-2007 2 0 08-2009
 Blood loss in ml
1200
1000
800
600 Group 1
1017
400 Group 2
200
277
0

Blood los s
 Group 1 < 500 ml Group 2 > 500 ml

Operative time 215,1 min (120 – 450) 239 min (120 – 480)

Hepatectomy 59,68 min ( 30 – 150) 70,37 min (30 – 130)

Blood loss 277,3 ml(50 – 500) 1017 ml ( 600 – 2300)

Hemotransfusion 3,64 ml (0 – 280 ) average 473 ml ( 0 - 1300) average

FFP 27,3 ml ( 0 – 270) average 178 ml ( 0 – 990)

average
Pringle 46 pts (59,7%) 48 pts (90,5%)

Pringle - clampage time 25,9 min ( 7 – 70) 27,3 min (10 – 70)
 Group 1 < 500 ml Group 2 > 500 ml

Operative time 215,1 min (120 – 450) 239 min (120 – 480)

Hepatectomy 59,68 min ( 30 – 150) 70,37 min (30 – 130)

Blood loss 277,3 ml(50 – 500) 1017 ml ( 600 – 2300)

Hemotransfusion 3,64 ml (0 – 280 ) average 473 ml ( 0 - 1300) average

FFP 27,3 ml ( 0 – 270) average 178 ml ( 0 – 990)

average
Pringle 46 pts (59,7%) 48 pts (90,5%)

Pringle - clampage time 25,9 min ( 7 – 70) 27,3 min (10 – 70)
 Group 1 < 500 ml Group 2 > 500 ml
Infusion 6,1 ml/kg ( 3 – 11) 8,3 ml/kg (4 – 18)

Coloids 268,2 ml average 665.7 ml average

CVP - beginning 6,6 mmHg 8,4 mmHg

CVP– hepatectomy 6,4 mmHg 8,2 mmHg

CVP– end 6,4 mmHg 7,9 mmHg

Diuresis 0,9 ml/kg /h (0,2 – 4,5) 1,8 ml/kg /h (0,4 – 6,4)

Hypotension 13 pts 22 pts

Vasopressor 13 pts 12 pts

Balance - infusion - 31,81ml 583, 15 ml

 Group 1 < 500 ml Group 2 > 500 ml
Infusion 6,1 ml/kg ( 3 – 11) 8,3 ml/kg (4 – 18)

Coloids 268,2 ml average 665.7 ml average

CVP - beginning 6,6 mmHg 8,4 mmHg

CVP– hepatectomy 6,4 mmHg 8,2 mmHg

CVP– end 6,4 mmHg 7,9 mmHg

Diuresis 0,9 ml/kg /h (0,2 – 4,5) 1,8 ml/kg /h (0,4 – 6,4)

Hypotension 13 pts 22 pts

Vasopressor 13 pts 12 pts

Balance - infusion - 31,81ml 583, 15 ml

 Group 1 < 500 ml Group 2 > 500 ml

ICU 62 pts (80 %) 52 pts (96,26%)

Intubation 32 pts (41,5 %) 43 pts (81,13%)

ICU - days 0,9 days 1,6 days

Postoperative 7 pts (9,09%) 15 pts (28%)

infection
Liver dysfunction 15 pts (19,48%) 27 pts (50,9%)

МОD* 3 pts (3,86%) 6 pts (11,3%)

Mean hospital stay 10,7 days ( 2 – 34) 14,13 days (6 – 36 )

Morbidity 2 pts (2, 59 %) 4 pts (7,54 %)

 Group 1 < 500 ml Group 2 > 500 ml

ICU 62 pts (80 %) 52 pts (96,26%)

Intubation 32 pts (41,5 %) 43 pts (81,13%)

ICU - days 0,9 days 1,6 days

Postoperative 7 pts (9,09%) 15 pts (28%)

infection
Liver dysfunction 15 pts (19,48%) 27 pts (50,9%)

МОD* 3 pts (3,86%) 6 pts (11,3%)

Mean hospital stay 10,7 days ( 2 – 34) 14,13 days (6 – 36 )

Morbidity 2 pts (2, 59 %) 4 pts (7,54 %)

 Morbidity

 Intraoperative mortality - 0 %
 Mortality rate – 5.17 %
 Group 1 – 3.12 %
 Group 2 – 13 %
 Relaparotomy for bleeding – 3 pts
(2.5 %)
Factors Contributing Bleeding
 Surgeon – the first and most important
 Aggressive Infusion
 Resection of v. cava inferior
 Operative time
 Child-Pugh score
 Liver parenchyma quality
 Localization of the lesion