Reply: Reduction of blood product transfusion requirements during liver transplantation

We thank Dr. E. Pivalizza et al. for their interest in our work. Only 44.5% of our patients underwent phlebotomy, and all patients in both series had aprotinin according to the Hammersmith protocol.1 Phlebotomy was one of the 3 variables linked to no red blood cell (RBC) transfusion during orthotopic liver transplantation (OLT) from logistic regression. We gave the odds ratio from the 304 patients studied; when we performed phlebotomy, the risk of transfusing RBC decreased from 79% to 13%. Moreover, we did not conclude that there was a causal relationship between phlebotomy and no RBC transfusions. Phlebotomy is a tool to decrease the central venous pressure (CVP), but it is not an end in itself. We believe that maintaining a low CVP is the most important clinical factor that permits OLT without transfusion. Regardless of which technique is used (phlebotomy or fluid restriction), it is the lowering of the CVP during liver dissection, before the anhepatic phase, that contributes to limit blood loss and hence leads to a decreased transfusion rate. Phlebotomy results in a faster decrease of the CVP when compared with fluid restriction. The purpose of our study was not to compare the level of morbidity between our patients and patients from other centers. We wanted to evaluate ways to transfuse less blood products in patients with comparable disease severity. Our patients, when compared with patients in other series, seem to be as sick, if not sicker. The patients of Frasco et al.,2 with a RBC transfusion rate of 2.9 ± 2.7 units per patient, had the same severity of disease for their patients as ours. The patients of Ramos et al.,3 who had the same transfusion rate for RBC, had a starting international normalized ratio of 1.2 ± 0.2. What is more, 40% of the patients in the last series received a diagnosis of hepatocellular carcinoma as a result of hepatitis C, vs. 7% in our series. A total of 73% of their patients came from their home. Finally, in our series, 13 patients had undergone a previous OLT, and some had undergone OLT and a renal transplant. We can add that after more than 200 OLTs performed at our center using this strategy, the transfusion rate is still the same. With this transfusion rate, it is very difficult to study strategies aimed at decreasing blood loss or transfusion rate. We are limited to observational studies or historical controls. We hope that other liver transplantation centers would undertake the study of these new concepts of not correcting coagulation defects, lowering CVP, or performing phlebotomy during OLT. Dr. Luc Massicotte*, Dr. Serge Lénis*, Dr. Lynda Thibeault , Dr. Marie-Pascale Sassine , Dr. Robert F. Seal?, Dr. Andre Roy?, * Department of Anesthesiology, Hôpital St-Luc (CHUM), Montreal, Quebec, Canada, Department of Epidemiology, Hôpital St-Luc (CHUM), Montreal, Quebec, Canada, Department of Biostatistics, Hôpital St-Luc (CHUM), Montreal, Quebec, Canada, ? Department of Anesthesiology, University of Alberta, Edmonton, Alberta, Canada, ? Department of Surgery, Hôpital St-Luc (CHUM), Montreal, Quebec, Canada

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