Anaesthesia management of major hepatic resections without application of allogeneic blood

In a prospective study we used acute normovolemic haemodilution (ANH) together with low CVP anaesthesia in order to avoid allogeneic blood transfusion during major liver surgery.

With institutional approval, 20 patients, ASA classification I-III, undergoing hepatic lobe resection consecutively (18 for metastatic cancer, 2 for hepatocellular cancer) in 2002, were enrolled into the prospective study. A epidural catheter was inserted before surgery in the thoracic region. General anaesthesia was induced and maintained with sevoflurane and fentanyl. Invasive haemodynamic monitoring was instituted. Blood was removed for ANH and circulation volume was replaced by infusion of colloids and crystalloid. The CVP was maintained less than 5 mm Hg during hepatic parenchymal transection. After procedure the ventilated patients were transported to ICU.

The preoperative haematocrit value (Hct) allowed performance of ANH with a blood removal (1025 +/- 357 g) in all patients. The estimated blood loss was 825 +/- 515 ml. None of the subject received allogeneic blood during surgery. One patient had transfusion of 2 units of allogeneic blood the fifth day after the right hepatectomy during a second look for perihepatic hematoma. The CVP was 3.8 +/- 0.4 mmHg during liver resection. Postoperative Hct was 0.31 +/- 0.02 and haemoglobin 108 +/- 11 g/L. All patients were extubated the first day after surgery. There was no hospital mortality.

We have shown that the routine use of new surgical techniques and low CVP anaesthesia in combination with ANH enabled avoidance of allogeneic blood transfusion in all patients during surgery. (Tab. 3, Ref. 22).