Acute normovolaemic haemodilution in cirrhotic patients undergoing major liver resection: Role of ROTEM

Background
Allogeneic blood transfusion increases the incidence of tumor recurrence and affects survival of patients undergoing liver resection. Acute normovolemic heamodilution (ANH) helps to decrease the exposure to allogeneic transfusion. This technique in cirrhotic patients undergoing major liver resection may compromise the coagulation process. Study of coagulation effects of ANH using rotation thromboelastometry (ROTEM), which provides global evaluation of coagulation function, may add beneficial effects.
Patients and methods
160 ASAII, Child A cirrhotic patients undergoing major hepatic resection were prospectively randomized into two equal groups; control and ANH group in which ANH was done. ROTEM (extem and fibtem) and conventional coagulation tests (CCT) (INR, fibrinogen level, and platelet count), were measured at baseline, 1 h after start of surgery, at the end of surgery and on 3rd and 5th postoperative days. Also blood lactate level and oxygen consumption were evaluated at the previous measuring points. The number of patients received allogeneic blood transfusion and the amount of blood received blood loss, fluid infused were recorded.
Results
ROTEM parameters of ANH group showed statistically significant changes compared to base line value and corresponding control values at 1 h after surgery. These changes were slightly outside the normal range, 1 h after surgery and within the normal reference range in all the following study points. Conventional coagulation parameters had the same pattern of changes but values were outside normal range all over the study period. ANH decreased the incidence of allogeneic packed red blood cell transfusion by 22.5% (28.75% vs. 6.25% of patients received packed red blood cells in control and ANH groups respectively) and plasma transfusion by 6.25% (13.75% vs. 7.5% of patients received plasma in control vs. ANH group respectively). No reported complications related to ANH were detected.
Conclusion
ROTEM added two benefits 1st it gave some clinical evidence of safety of ANH associated coagulation changes which may encourage more degree of haemodilution in this category of patients. Second the use of ROTEM triggered transfusion parameters seemed to help decrease plasma transfusion requirement which serves the aim of ANH.