Reduced need for blood with new liver

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From an average of eight bags of blood per operation, to just one. Plus healthier patients, fewer complications and going home sooner. This is a development that the transplantation unit at Karolinska University Hospital can add to its list of achievements thanks to new liver transplantation routines.

For many years, ever since the country's first liver transplantations were carried out in Huddinge hospital in 1984, operations involving the liver have required large blood transfusions and long hospital stays for the patient. The situation today is rather different.

"The patient can be woken up on the operation table, sit up on the edge of the bed the same day, start standing up and even start walking the next day!"

A new procedure

So says Anna Januszkiewicz, an anaesthesia consultant and Function Unit Director for Transplantation, Anaesthesia at Karolinska University Hospital, Huddinge. Together with a team of anaesthetists, nurse-anaesthetists and surgeons – all specialising in transplantation, she has come up with a new procedure for liver transplantation. It contains guidelines and routines that result in healthy patients faster, as well as patients who are healthier throughout the operation, and to top it all off, with a significantly reduced need for blood transfusion as a result. On average, the need for bags of blood during liver transplants has fallen from eight to one. But this could be even better, with a goal of reducing this to zero bags.

Anna Januszkiewicz has not needed to re-invent the wheel, however. The change implemented by the team has made use of research results from other countries in combination with the care provided at Karolinska University Hospital.

"The thinking about patients with liver disease has changed dramatically over the past fifteen years," explains Anna Januszkiewicz when discussing the change.

Patients with liver disease were very often given extra blood products as a preventive measure. However, research showed that the blood given to patients during liver transplantation resulted in longer hospital stays, more complications and a risk of worsened patient survival.

"The odds of keeping the new liver can also be worse for patients who are given a lot of blood transfusions," explains Anna Januszkiewicz.

The box used to transport the liver to be transplanted.

At many hospitals around the world, consideration was therefore given to how liver transplantation could be performed with less supplied blood. At the beginning of the millennium, research showed that the body has an ingenious and extremely complicated interplay, regardless of whether the liver is healthy or diseased. Researchers found that the sensitive balance between blood clots and bleeding, in other words the liver's ability to control coagulation and anticoagulation, is preserved – even in patients with liver disease. The sensational finding was that even a diseased liver is still able to perform the many important roles in this interplay.

"If a liver is diseased, in most cases both of these functions are affected to the same degree, but the balance between them is preserved. At the same time, this balance in the liver is very delicate, and a lot of factors can affect it, for example adding blood products for preventive purposes," explains Anna Januszkiewicz, who started collecting the research results just over 10 years ago.

Thanks to a joint effort, the team at the liver transplantation unit was able, in 2011, to implement the results from the studies into their own activities, and to start applying new, strict guidelines for supplying both blood and fluid during surgery.

The need for blood during transplantation then fell significantly. Before then, between the years 2005 and 2009, patients were given an average of 8 bags of blood, a figure that immediately fell to three – and which has since fallen even further to an average of 1 bag per liver transplantation.

The team is assisted during an operation by a medical-technical device that shows exactly how coagulation of the blood is functioning in the patient on the operating table. A further factor is blood samples and rapid laboratory results, which continuously give the team a picture of the concentrations of various substances in the patient's blood. This, together with the clinical picture and advanced monitoring of heart function, gives surgeons, nurses and anaesthetists the information they need to work out exactly how much blood and fluid the patient needs for optimum health during and after the operation.

Better quality of life

"When patients bleed less, they are more stable, they are healthier and they can be woken up immediately after the operation. As a result, so-called post-operative care in the intensive care department, after the operation, is shorter and patients can usually be transferred to the nursing department as early as the next day. Thanks to this new procedure, there has been a dramatic reduction in complications. They also go home sooner, usually after just ten days, when before this could have taken several weeks," says Anna Januszkiewicz, who is proud of what the team has achieved:

"The new procedure has resulted in better quality of life for the patient, shorter hospital stays and less time off work. The patients are happy, and we ourselves love what we do. There is a great enthusiasm for working on liver transplantation, despite the fact that it can be hard work and with really long sessions."

Text and photo: Carin Tellström