J. N. Leal1, T. P. Kingham1, P. J. Allen1, R. P. DeMatteo1, W. R. Jarnagin1, M. I. D’Angelica1 1Memorial Sloan-Kettering Cancer Center,Surgery,New York, NY, USA
Introduction:
Following hepatectomy INR is often elevated and elicits concern regarding increased bleeding risk. This can lead to transfusion of fresh frozen plasma (FFP) and/or delay the institution of venous thromboembolism (VTE) prophylaxis. INR, however, does not accurately reflect coagulation status following hepatectomy, and despite observed elevations, hypercoaguability and thrombosis are common. The clinical usefulness of the INR following hepatectomy is therefore questionable. The purpose of this study is to characterize current practice patterns regarding INR, FFP transfusion triggers and VTE prophylaxis following hepatectomy amongst a group of liver surgeons.
Methods:
A survey addressing FFP transfusion triggers and characteristics of VTE administration following hepatectomy was developed and distributed to the active membership of America’s Hepatopancreaticobiliary Association (AHPBA). Results were summarized for the group as a whole and then stratified into groups based on reported number of hepatectomies/year; Group A (≥50 hepatectomies/year) and Group B (< 50 hepatectomies/year), and responses compared.
Results:
Surveys were emailed to active members of the AHPBA (n=971). Overall 174(18%) surveys were completed. Post operative FFP transfusion rate was estimated to be <25% by the majority or respondents (149, 86%). The most commonly reported trigger for FFP transfusion was clinical evidence of bleeding (42%). However, over a third of participants (63, 36%) reported using isolated INR elevation as the sole trigger for FFP transfusion. Amongst these respondents the level of INR triggering FFP transfusion varied considerably (range 1.5-2.0). VTE prophylaxis following liver resection was reported to be utilized by 94% of respondents, however, only 54% of gave it in accordance with current guidelines. Elevated INR was reported as the reason for not implementing VTE prophylaxis at all (8, 5%) or delaying implementation for >24 hrs (61, 35%). No differences between groups A (n=82) and B (n=90) in terms of type of transfusion trigger was observed (p=0.18). However, a trend towards use of a higher INR (>1.8) as the trigger point in group A compared to group B was observed (Figure 1, p=0.07). No differences between groups were observed with regards to type and timing of VTE prophylaxis.
Conclusion:
Despite recent evidence questioning the accuracy of INR following liver resection; its use as a trigger for transfusion and/or delay in VTE prophylaxis remains common. In centers where higher numbers of hepatectomies are performed it appears tolerance for higher INR prior to transfusion may exist.
