David Wuest

Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia : Blood loss, blood transfusion, and the risk of postoperative renal dysfunction

BACKGROUND We have previously demonstrated that maintenance of a low central venous pressure (LCVP) combined with extrahepatic control of venous outflow reduced the overall blood loss during major hepatic resections. This study examined the overall outcomes and, in particular, renal morbidity associated with a large series of consecutive major liver resections performed with this approach. In addition, the rationale for the anesthetic management to maintain LCVP was carefully reviewed. STUDY DESIGN All major hepatectomies performed between December 1991 and April 1997 were reviewed. The prospective Hepatobiliary Surgical Service database was merged with the Memorial Hospital Laboratory and Blood Bank databases to yield the nature of the operation, blood loss, blood product transfusions, outcomes, and levels of preoperative, postoperative, and discharge serum creatinine and blood urea nitrogen. RESULTS A total of 496 LCVP-assisted major liver resections were performed, with no intraoperative deaths and an in-hospital mortality rate of 3.8%. The median blood loss was 645 mL. Sixty-seven percent of the patients did not require perioperative blood transfusion during surgery and the immediate 12 hours after surgery. The median number of blood transfusions was 2. Only 3% of the patients experienced a persistent and clinically significant increase in serum creatinine possibly attributable to the anesthetic technique. Renal failure directly attributable to the anesthetic technique did not occur. CONCLUSIONS Major resection with LCVP allowed easy control of the hepatic veins before and during parenchymal transection. The anesthetic technique, designed to maintain LCVP during the critical stages of hepatic resection, not only helped to minimize blood loss and mortality but also preserved renal function.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

ObjectiveTo determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer. Summary Background DataBlood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies. MethodsBlood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed. ResultsBlood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome. ConclusionsPerioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.

A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection.

Background:Hepatic resection is the most effective treatment for many malignant and benign conditions affecting the liver and biliary tree. Despite improvements, major partial hepatectomy can be associated with considerable blood loss and transfusion requirements. Transfusion of allogeneic blood products, although potentially life-saving, is associated with many potential complications. The primary aim of this study was to determine if acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces the requirement for allogeneic red cell transfusions in patients undergoing major hepatic resection. Methods:One hundred thirty patients undergoing major hepatic resection (≥3 segments) were prospectively randomized to undergo either ANH or standard anesthetic management (STD). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL. Low central venous pressure anesthetic technique was used intraoperatively for both groups. A standardized transfusion protocol was applied to all patients intraoperatively and throughout the hospital stay. Results:From April 2004 to March 2007, 63 patients were randomized to ANH and 67 to STD. Demographics, diagnoses, liver function, extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, and length of hospital stay were similar between the 2 groups. ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD [12.7% (n = 8) vs. 25.4% (n = 17), respectively; P = 0.067. ANH patients were less often transfused intraoperatively (n = 1, 1.6%) compared with the STD group (n = 7, 10.4%) (P = 0.036), had higher postoperative hemoglobin levels (P = 0.01), and tended to require fewer red cell units overall (28 vs. 47 units). In patients with intraoperative blood loss ≥800 mL, ANH reduced not only the allogeneic red cell transfusion rate (18.2% vs. 42.4%, P = 0.045) but also the proportion of patients requiring fresh frozen plasma (21.1% vs. 48.3%, P = 0.025). Conclusion:For patients undergoing major liver resection, ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use. Given the modest transfusion rate in the STD arm, future efforts should attempt to target ANH use to patients most likely to benefit.

N7: a novel multi-modality therapy of high risk neuroblastoma (NB) in children diagnosed over 1 year of age.

BACKGROUND The N7 protocol for poor-risk neuroblastoma uses dose-intensive chemotherapy (as in N6 protocol [Kushner et al.: J Clin Oncol 12:2607-2613, 1994] but with lower dosing of vincristine) for induction, surgical resection and 2100 cGy hyperfractionated radiotherapy for local control, and for consolidation, targeted radioimmunotherapy with 131I-labeled anti-GD2 3F8 monoclonal antibody and immunotherapy with unlabeled/unmodified 3F8 (400 mg/m2). PROCEDURE The chemotherapy consists of: cyclophosphamide 70 mg/kg/d x 2 and a 72-hr infusion of doxorubicin 75 mg/m2 plus vincristine 2 mg/m2, for courses 1, 2, 4, and 6; and cisplatin 50 mg/m2/d x 4 and etoposide 200 mg/m2/d x 3, for courses 3, 5, and 7. 131I-3F8 is dosed at 20 mCi/kg, which is myeloablative and therefore necessitates stem-cell support. RESULTS Of the first 24 consecutive previously untreated patients more than 1 year old at diagnosis, 22 were stage 4 and two were unresectable stage 3 with MYCN amplification. Chemotherapy achieved CR/VGPR in 21 of 24 patients. Twenty patients to date have completed treatment with 131I-3F8, and 15 patients have completed all treatment. With a median follow-up of 19 months, 18 of 24 patients remain progression-free. CONCLUSIONS Major toxicities were grade 4 myelosuppression and mucositis during chemotherapy, and self-limited pain and urticaria during antibody treatment. Late effects include hearing deficits and hypothyroidism.

Use of Preoperative Autologous Blood Donation in Liver Resections for Colorectal Metastases

BACKGROUND Transfusion of allogeneic blood is associated with risks of human immunodeficiency virus and hepatitis transmission, transfusion reactions, and other potential immunologic and infectious complications. To determine if predonation of autologous blood impacts upon transfusion practice and clinical outcome following liver resection, clinical records of 379 consecutive patients undergoing hepatic resection for metastases of colorectal cancer were identified from the prospective hepatobiliary database and reviewed. METHODS Of the 379 hepatic resections performed for colorectal metastases between January 1991 and January 1996, 240 (63%) were hepatic lobectomy or trisegmentectomy. Thirty-two percent of patients (123 of 379) agreed to preoperative blood donation (POBD), and their clinical characteristics including age, preoperative hemoglobin, and operative mortality were comparable with those of patients without POBD. Liver resections were carried out using standard vascular inflow and outflow control. Parenchymal transections were performed bluntly with maintenance of low central venous pressure (0 to 5 cm H2O). No vascular isolation or normovolemic hemodilution was used intraoperatively. All erythrocyte transfusions during the entire hospital stay were considered and compared between the two groups. RESULTS Forty-five percent of patients (172 of 379) received blood transfusions during or after liver resections, of which 61% (105 of 172) required only 1 or 2 units. Only 17% of the POBD group required allogeneic blood. This was significantly less than the group without POBD (43%, P <0.01). There was no significant difference in the operative mortality (2.3% versus 4.9%, P = 0.2) and the median survival (50 versus 40 months, P = 0.3). CONCLUSIONS Major hepatic resections using current surgical techniques can be performed safely with low blood loss and transfusion is required for only a minority of patients. POBD further reduces transfusion requirement.

Transfusion policy: when to stop the use of extremely rare blood for an allogeneic hematopoietic progenitor cell transplant recipient with a history of red cell alloimmunization

BACKGROUND: Decisions for when to select, and when to discontinue, antigen‐negative blood in hematopoietic progenitor cell transplantation (HPCT) recipients with red blood cell (RBC) antibodies can be confusing. In HPCT performed for sickle cell anemia patients who require extremely rare antigen‐negative blood, the balance of caution and practicality is further complicated.

Chapter 17 – Washed and Volume-Reduced Components

Publisher Summary Reactions of patients to the transfusion of packed red blood cells (PRBCs) and other blood components are commonly categorized as febrile, allergic, volume related, or not related to transfusion. Washing and/or volume-reducing cellular blood components are manipulations designed to remove presumed or potential offending plasma proteins or to make the infused volume compatible with the patients size or cardiovascular status. Patients who are IgA-deficient and have anti-IgA can experience life-threatening anaphylactic transfusion reactions. When neither IgA-deficient donors nor frozen PRBCs are available, it is recommended that liquid PRBCs should be used (washed twice with a liter of saline per PRBC unit). Platelets as well as PRBCs may be washed on automated cell washers without functional compromise—a fact that has clear-cut implications with respect to the management of allergic transfusion reactions. However, platelet viability and function appear to be affected by the composition of the wash solution, and the number of platelets in the product is substantially reduced following washing. Further, the modification of component volume is a common practice in pediatric transfusion because components are dosed not in units but in milliliters per kilogram and are often administered by syringe or “pedi unit.” In adults, units of PRBCs and other components can be split or centrifuged to allow excess plasma to be extracted manually to reduce the volume infused to patients at risk of volume overload because of severe congestive heart failure or cardiomyopathy.

Chapter 16 – Irradiated Components

Publisher Summary In transfusion associated graft-versus-host (TA-GVHD) patients, the intensity of the mixed lymphocyte reaction can be decreased by either reducing the number of unirradiated responding cells or increasing the dose of gamma irradiation to responding cells. For an institutional policy of blood component irradiation to fulfill its preventive function, patients at risk for TA-GVHD must be reliably identified prospectively. Blood components that must be irradiated for categories of patients at risk include packed red blood cells (PRBCs), granulocytes, platelets, platelet-rich plasma, freshly separated plasma, and buffy coats used to treat neonatal sepsis. Frozen deglycerolized PRBCs can also be a source of immunocompetent lymphocytes capable of causing TA-GVHD and therefore must be irradiated for indicated categories of patients. Human leukocyte antigen (HLA)-matched apheresis platelets must always be irradiated. Donor lymphocyte infusions (DLIs) may or may not be irradiated 0depending on the indication for their use: those used to treat viral infections should be irradiated, while those used as therapy for disease recurrence post-allograft should not be irradiated. Although some variation in dosing of irradiation still exists, with centers using anywhere from 15 to 50 Gy, the data with respect to the ability of lymphocytes to proliferate in mixed lymphocyte cultures or in response to mitogens indicate that a small fraction of T-lymphocytes retain some proliferative capacity even at 30 Gy. Current standards require a dose not less than 25 Gy to the central midplane of the irradiation field, and this dose appears to be appropriate for clinical indications.