Review
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World J Hepatol. Jan 27, 2013; 5(1): 1-15
Published online Jan 27, 2013. doi: 10.4254/wjh.v5.i1.1
Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation
Feltracco Paolo, Brezzi Marialuisa, Barbieri Stefania, Galligioni Helmut, Milevoj Moira, Carollo Cristiana, Ori Carlo
Feltracco Paolo, Brezzi Marialuisa, Barbieri Stefania, Galligioni Helmut, Milevoj Moira, Carollo Cristiana, Ori Carlo, Department of Medicine UO Anesthesia and Intensive Care, University Hospital of Padova, Via Cesare Battisti, 256, 35128 Padova, Italy
Author contributions: Paolo F and Marialuisa B performed the literature search and drafted the article; all other authors made substantial contributions in completing the manuscript, revising it for important intellectual content, and approving the version to be submitted.
Correspondence to: Feltracco Paolo, MD, Department of Medicine UO Anesthesia and Intensive Care, University Hospital of Padova, Via Cesare Battisti, 256, 35128 Padova, Italy. paolofeltracco@inwind.it
Telephone: +39-49-8218285 Fax: +39-49-8218289
Received: August 9, 2012
Revised: January 7, 2013
Accepted: January 18, 2013
Published online: January 27, 2013
Abstract

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.

Keywords: Transplantation surgery, Liver dysfunction, Liver transplant, Intraoperative bleeding, Intraoperative transfusion, Autotransfusion, Autologous transfusions, Transfusion requirements, Blood salvage, Cell salvage