Transfusion-free strategies in liver and pancreatic surgery

Abstract

Presenter: Sujit Kulkarni MD | University of Southern California Background: Major liver and pancreatic resections often require peri-operative transfusions. This limits surgical options for patients who do not accept major blood fractions and elevates morbidity risks for those who do accept allogeneic blood products. Methods: A 23-year, single center, retrospective review of Jehovah’s Witness (JW) patients undergoing liver and pancreatic resections was performed, and patient outcomes were measured. A model that reconciles potential blood losses with blood conservation by acute normo-volemic hemodilution (ANH) is described. Results: Seventy-six JW patients underwent major resections (47 livers, 29 pancreas). ANH was utilized in 50 patients (liver 31, pancreas 19) with removal of ANH (median 2 units) that were returned once hemostasis was assured. There were no perioperative mortalities. Clavien-Dindo Grade ≥ 3 morbidity occurred in patients with liver resection (8.5%), pancreato-duodenectomy (16.6%), and distal pancreatic resections (9%). A quantitative mathematical formula was developed to provide guidance for optimizing the use of ANH to maintain hemodynamic stability and prevent the need for blood transfusion. Conclusion: Intra-operative whole blood removal with ANH preserves red cell mass, platelets, and coagulation factors for timely reinfusion making transfusion-free major hepato-biliary-pancreatic resections feasible. Application of the described strategy will help reduce costs, infection rates, and minimize transfusion in mainstream populations.