title: Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections.
abstract: Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations.
  
  
  
  Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H2O). The target phlebotomy volume was 7-10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison.
  
  
  
  A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3 cm H2O (0-15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications.
  
  
  
  Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
authors.forename: Janelle
authors.initials: J
authors.lastname: Rekman
authors.affiliation: Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
authors.forename: Christopher
authors.initials: C
authors.lastname: Wherrett
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
authors.forename: Sean
authors.initials: S
authors.lastname: Bennett
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
authors.forename: Miso
authors.initials: M
authors.lastname: Gostimir
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
authors.forename: Sara
authors.initials: S
authors.lastname: Saeed
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
authors.forename: Kristina
authors.initials: K
authors.lastname: Lemon
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
authors.forename: Richard
authors.initials: R
authors.lastname: Mimeault
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON.
authors.forename: Fady K
authors.initials: FK
authors.lastname: Balaa
authors.affiliation: Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON. Electronic address: gumartel@ottawahospital.on.ca.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Martel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion; D015331:Cohort Studies; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects* / Q000379:methods*; D065386:Historically Controlled Study; D006801:Humans; D020896:Hypovolemia / Q000209:etiology*; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D018962:Phlebotomy