Current practices in perioperative blood management
for patients undergoing liver resection: a survey of surgeons
Sean Bennett ,
Daniel I. McIsaac,
and Guillaume Martel
Development of intraoperative
techniques and blood management strategies in liver
resection, and the multidisciplinary nature of
perioperative transfusion decision making, creates an
opportunity for practice variation. The aim of this study
was to describe the current practices in perioperative
blood management and explore differences between
surgeons and anesthesiologists.
STUDY DESIGN AND METHODS:
survey was developed, piloted, and circulated to Canadian
liver surgeons and anesthesiologists. The survey focused
on management of preoperative anemia, blood
conservation strategies, estimation of blood loss, and
transfusion decision making in a multidisciplinary setting.
A total of 198 physicians received the
survey, with 117 responding (59%). Most responding
surgeons (67%) perform more than 20 liver resections
per year, while most responding anesthesiologists (90%)
take part in fewer than 20. Anesthesiologists most
commonly stated that preoperative anemia is managed
by someone else (38%), while surgeons most commonly
reported “no specific treatment” (45%). The most
common intraoperative blood conservation technique
used is administration of antifibrinolytics (63% used them
at least occasionally). The most important factor for
anesthesiologists when deciding on an intraoperative
transfusion was hemoglobin value (47%); for surgeons, it
was patient hemodynamics (33%). Compared to when
they started their career, 60% of respondents felt that
they were less likely to transfuse a patient now.
The results of our survey provide
insights into current transfusion practice and decision
making in liver resection, including a comparison between
anesthesiologist and surgeon transfusion behavior.
Management of preoperative anemia, increased use of
intraoperative blood conservation techniques, and
improved communication between providers were
identified as targets for quality improvement.
erioperative blood management for patients
undergoing liver resection has changed a great
deal over the past several decades. Advances in
surgical and anesthetic techniques and altera-
tions in the definitions of resectability have changed how
patients are managed before, after, and during surgery.
Currently, manipulation of the central venous pressure,
vascular clamping techniques, dissection devices, topical
hemostatic agents, and pharmacologic agents such as
antifibrinolytics are used to reduce blood loss in liver sur-
The introduction of these techniques, in addition to
changes in transfusion thresholds over time,
have decreased transfusion rates overall, with a large,
single-center study demonstrating a decrease in transfu-
sion prevalence from 83% in the late 1980s to 43% in the
Current evidence suggests that approximately
22% of liver resection patients in North America receive a
There is limited high-quality
evidence on the impact of blood loss and blood transfu-
sions in liver resection, although some retrospective data
ABBREVIATIONS: ANH 5 acute normovolemic
hemodilution; PACU 5 postanesthesia care unit.
Liver and Pancreas Unit, Department of Surgery,
Department of Medicine,
Faculty of Medicine, and the
Department of Anesthesiology and Pain Medicine, University
of Ottawa, Ontario; and the
Clinical Epidemiology Program,
Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
Address reprint requests to: Dr Guillaume Martel, The
Ottawa Hospital–General Campus, 501 Smyth Road, Ottawa,
ON, Canada, K1H 8L6; e-mail: email@example.com.
Presented at the 2017 Americas HepatoPancreatoBiliary
Association Annual Meeting, March 2017, Miami Beach, FL.
Received for publication September 25, 2017; and
accepted November 6, 2017.
Volume 58, March 2018 TRANSFUSION 781