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Copyright © 2003 American College of Surgeons. Published by Elsevier Science Inc.
Letter to the editor
Restricting fresh frozen plasma in hepatic resections
Singh Gagandeep MDa, Nicolas Jabbour MDa, Yuri Genyk MDa and Rick Selby MDa
a , Los Angeles, CA, USA
Available online 23 July 2003.
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Article Outline
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We enjoyed reading the article by Martin and colleagues[1] regarding the use of fresh frozen plasma (FFP) in liver resection. We, at USC/Keck School of Medicine, have established ourselves as a center of excellence for transfusion-free surgery and expanded our understanding in the management of coagulopathy in major hepatobiliary surgery. This paper prompted us to analyze our own experience with live donor hepatectomy for the purposes of transplantation, which we are currently in the process of submitting. We have done, to date, a total of 81 donor hepatectomies, 60 right lobectomies (74%), 4 left lobectomies, and 17 left lateral segmentectomies. Our highest recorded prothrombin time (PT) postoperatively was 22.7 seconds, and the mean postoperative PT was 15.35 ± 2.39 seconds. We did not use FFP in any of these liver resections. Only one unit of packed red cells was used for precipitous intraoperative hypotension from bleeding, which was rapidly controlled. It is our contention that FFP is not warranted unless there is evidence of bleeding associated with significant coagulopathy. PTs as high as 22 and possibly higher can safely be watched closely. We have not had any patient return to the operating room for bleeding or die postoperatively. In addition, we have also transplanted 11 Jehovah Witness patients from live donors. We did not use any blood product in these recipients despite an average postoperative PT of 18.8 ± 5.5 seconds. [2] We believe that FFP is not warranted in the majority of these patients and do not completely agree with the guidelines offered by authors to use FFP for PTs between 16 and 18 seconds.
Although the intent of replenishing the coagulation factors with FFP is reasonable, the benefit derived from the clotting factors is hard to evaluate. From our experience, the elevated PT in itself is seldom responsible for postoperative bleeding and is usually used as an indicator of recovery of liver function. The surgical community at large uses PT indiscriminately to evaluate coagulopathy; a more qualitative thromboelastogram would provide more information and justify the appropriate use of coagulation products.[3] With the community now more aware of the risks of transmission of diseases, [4] albeit low, a general caution in the patient's mind warrants a thoughtful usage of blood products. In this era of fiscal limitations, when surgeons are the largest consumers of blood products, it is our contention that curtailing the liberal usage of FFP does not affect the final outcomes.
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References
1. R.C. Martin, W.R. Jarnagin, Y. Fong et al., The use of fresh frozen plasma after major hepatic resection for colorectal metastasis: is there a standard for transfusion?. J Am Coll Surg 196 (2003), pp. 402–409. Abstract-EMBASE | Abstract-Elsevier BIOBASE | Abstract-MEDLINE | $Order Document
2. Jabbour N, Gagandeep S, Mateo R, et al. Live donor liver transplantation without blood products. Strategies developed for Jehovah's Witnesses offer broad application (unpublished data)
3. Y. Kang, Thromboelastography in liver transplantation. Semin Thromb Hemost 21 Suppl 4 (1995), pp. 34–44. Abstract-EMBASE | Abstract-MEDLINE | $Order Document
4. M.P. Busch, S.H. Kleinman and G.J. Nemo, Current and emerging infectious risks of blood transfusions. JAMA 289 (2003), pp. 959–962. Abstract-MEDLINE | $Order Document | Full Text via CrossRef
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| |Journal of the American College of Surgeons |
| |Volume 197, Issue 2 , August 2003 , Pages 339 |
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