An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery

In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects - e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.     

An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery

In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects--e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.     

学龄前儿童先天性脊柱侧凸矫形手术围术期输血的相关因素分析——一项单中心回顾性分析

目的回顾性分析学龄前儿童（≤72个月）行先天性脊柱侧凸矫形手术围术期血液管理的临床特点及相关影响因素。方法针对2年以来行先天性脊柱侧凸矫形手术的110例学龄前儿童（≤72个月）相关资料进行回顾性分析,组间比较采用t检验,组内比较采用重复测量的方差分析,多元Logistic回归分析被用来确定异体红细胞输注的独立预测因子。结果共有91例患儿（83％）术中输入异体红细胞,与术中异体红细胞输入量存在明显相关性的因素有患儿的体重、术前Cobb角、融合节段、手术时间、截骨数量、失血量以及术前血红蛋白（hemoglobin,Hb）浓度、红细胞比容（hematocrit,Hct）、血小板（bloodplatelet,Pit）计数,其中独立因素有Cobb角、截骨数量、术前Hb浓度、Hct、Pit计数。输血患儿与未输血患儿比较,术中截骨率、术中出血量和术后24h伤口引流量显著增加,术后住院时间也明显延长。结论可作为围术期输血评估的独立因素有Cobb角、截骨数量、术前Hb浓度、Hct、Plt计数,而与患儿的年龄、体重、融合节段及手术时间无明显相关性,有助于对学龄前儿童先天性脊柱侧凸矫形手术围术期输血需求的早期识别和准确评估,保证患儿的生命安全。     

Identification of risk factors for allogenic transfusion in cardiac surgery from an observational study

OBJECTIVE: To determine perioperative variables for predicting allogenic transfusion in adult cardiac surgery. STUDY DESIGN: Prospective study. PATIENTS: We included 335 consecutive patients undergoing cardiac surgery between February and April 2001. METHODS: Perioperative variables were prospectively collected in a database. For each patient who received transfusion, hemoglobin threshold for transfusion and total number of units of red cell concentrates were collected. Univariate and multivariate analysis were performed. RESULTS: The two strategies for blood conservation which were predominantly used were aprotinin therapy (78%) and blood salvage from the extracorporeal circuit (68%). During perioperative period, 42% of patients [95% CI: 37-47%] received allogenic transfusion. The haemoglobin threshold for transfusion was 7.4 +/- 1.1 and 8.0 +/- 0.7 g x dl(-1) in operating room and in intensive care unit, respectively. On average, 3.4 +/- 2.7 units of red cell concentrates were transfused perioperatively per patient. Using multivariate analysis, perioperative allogenic transfusion was significantly associated with the following variables: preoperative haemoglobin level < 12 g x dl(-1) (odds ratio 8.9; p = 0.001), emergency procedure (odds = 3.7, p = 0.01), reoperation (odds ratio = 3.3; p = 0.002), chronic obstructive pulmonary disease (odds ratio = 2.5; p = 0.03) and complex surgery (odds ratio = 2.4; p = 0.01). The age, the gender, and body mass index were only independent risk factors by univariate analysis. CONCLUSION: In despite of techniques to limit requirement of allogenic transfusion, a large proportion of cardiac surgical patients remains transfused. Independent risk factors of perioperative transfusion are haemoglobin level < 12 g x dl(-1), emergency procedure, reoperation, chronic obstructive pulmonary disease and complex surgery.     

预存自体输血在全髋关节置换手术中的应用

目的：探讨全髋关节置换手术减少异体输血的措施，介绍一种较理想的自体输血方法。方法：自1997年12月－2001年1月，对80例全髋关节置换手术患者进行了预存自体输血。采血前、后前4d检测血红蛋白（HGB），红细胞（RBC），红细胞压积（HCT），结果：预存自体血23700ml,平均409ml，58例（72．5％）患者无需异体输血顺利度过围手术期，22例（27．5％）患者补充异体输血7392ml，平均336ml，而同期未做预存自体输血者输异体血69741ml，平均567ml，没有发生与预存自体输血相关的并发症。结论：预存自体输血简便，经济、安全、有效，全髋关节置换手术患者基本上依靠预存自体输血能安全度过围手术期。     

Combination of acute normovolemic hemodilution technique with preoperative autologous blood donation prevented allogeneic blood transfusion against 4000 g surgical blood loss in a patient undergoing left partial nephrectomy

A 41-year-old male patient with well-controlled hypertension underwent a partial nephrectomy under total intravenous anesthesia with propofol, fentanyl and ketamine. To avoid allogeneic blood transfusion, preoperative autologous blood donation (400 g) a week before the surgery and acute normovolemic hemodilution (800 g) after induction of anesthesia were performed. As surgical blood loss was more than 4000 g, blood hemoglobin (Hb) level decreased to 6.4 g.dl-1. However, as intraoperative hemodynamics was relatively stable with no ischemic changes in ECG and arterial blood gas analysis did not show metabolic acidosis, autologous blood transfusion was withheld till hemostasis had been done. After returning the autologous blood, Hb increased to 9.4 g.dl-1. On the 2nd postoperative day, Hb decreased to 7.6 g.dl-1. As the patient's vital signs did not show any severe complications, blood transfusion was not performed. Then, the Hb level increased gradually to 13.9 g.dl-1, 3 month later without allogenic blood transfusion. In addition, any postoperative complications by low Hb level were not recognized so far. This case suggests that combination of autologous transfusion techniques may be effective to avoid allogeneic blood transfusion even against massive hemorrhage. However, to avoid disadvantage of these technique, we should always evaluate preoperative patient conditions.     

Perioperative Anämietoleranz

The expected cost explosion in transfusion medicine (increasing imbalance between donors and potential recipients, treatment of transfusion-associated complications) increases the socio-economic significance of specific institutional transfusion programs. In this context the estimated use of the patient's physiologic tolerance to anemia enables 1) the tolerance of larger blood losses (loss of "diluted blood"), 2) the onset of transfusion to the time after surgical control of bleeding to be delayed and 3) the perioperative collection of autologous red blood cells. The present review article summarizes the mechanisms, influencing factors and limits of this natural tolerance to anemia and deduces the indication for perioperative red blood cell transfusion. Under strictly controlled conditions (anesthesia, normovolemia, complete muscular relaxation, hyperoxemia, mild hypothermia) extremely low hemoglobin concentrations [Hb <3 g/dl (<1.86 mmol/l)] are tolerated without transfusion by individuals with no cardiopulmonary disease. In the clinical routine these situations are limited to borderline situations e.g. unexpected massive blood losses in Jehovah's Witnesses or unexpected shortcomings in blood supply. The current recommendations coincide to the effect that perioperative red blood cell transfusion 1) is unnecessary up to a Hb concentration of 10 g/dl (6.21 mmol/l) even in older patients with cardiopulmonary comorbidity and 2) is only recommended in cases of Hb <6 g/dl (<3.72 mmol/l) in otherwise healthy subjects including pregnant women and children. Critically ill patients with multiple trauma and sepsis do not seem to benefit from transfusions up to Hb concentrations >9 g/dl (>5.59 mmol/l). In cases of massive hemorrhaging and diffuse bleeding disorders the maintenance of a Hb concentration of 10 g/dl (6.21 mmol/l) seems to contribute to stabilization of coagulation.     

Incidence and risk factors for allogenic blood transfusion during major joint replacement using an integrated autotransfusion regimen. The Rizzoli Study Group on Orthopaedic Anaesthesia

The efficacy of an integrated autotransfusion regimen, including pre-donation and perioperative salvage of autologous blood, was prospectively evaluated in 2884 patients undergoing total hip (n = 2016) or knee arthroplasty (n = 480), and hip revision (n = 388) with either balanced general, regional, or integrated epidural/general anaesthesia. Allogenic concentrated red blood cells were transfused in the presence of symptomatic anaemia or when haemoglobin concentration was < 6 g dL-1 (10 g dL-1 in patients affected by cerebrovascular or coronary artery disease) after all salvaged and pre-donated autologous blood had been transfused. A total of 278 patients (9.6%) received allogenic blood. Risk factors for allogenic blood transfusion were: preoperative haemoglobin concentration < 10 g dL-1 (after autologous blood pre-donations) (Odds ratio: 8.7; 95% CI: 6.5-16.8; P = 0.004), hip revision versus hip or knee arthroplasty (Odds ratio: 5.8; 95% CI: 3.9-8.5; P = 0. 0001) and inability in obtaining the number of pre-donations required by the Maximum Surgery Blood Order on Schedule (Odds ratio: 3.4; 95% CI: 2.7-4.1; P = 0.0001). The incidence of perioperative complications, including wound infection and haematoma, as well as myocardial ischaemia, respiratory failure and thromboembolic complications, was higher in those patients requiring allogenic blood transfusion (29.8%) than that observed in patients receiving only autologous blood (6.6%) (P = 0.0005); while the mean time duration from surgical procedure to patient discharge from the orthopaedic ward was shorter in those patients not receiving allogenic blood transfusion (12 days; 25-75th percentiles: 8-14 days) than in those patients who required perioperative transfusion with allogenic blood (15 days; 25-75th percentiles: 10-17 days) (P = 0.0005). In conclusion, this prospective study highlighted the clinical relevance of applying an extensive and integrated autotransfusion regimen in order to reduce allogenic blood transfusion and associated complications in patients undergoing major joint replacement.     

Blood use in lung resection for carcinoma: perioperative elective anaemia does not compromise the early outcome.

OBJECTIVE: Blood transfusion may adversely affect the prognosis following surgery for non-small cell lung carcinoma (NSCLC). Conventionally by most thoracic surgeons, a perioperative haemoglobin (Hb) less than 10 g/dl has been considered a transfusion trigger. In this prospective trial we have (a) evaluated the overall blood transfusion requirements and factors associated with an increased need for transfusion and (b) in a subsequent subset of patients, tested the hypothesis that elective anaemia after major lung resection may be safely tolerated in the early postoperative period. METHODS: A total of 198 (M/F 179/10, mean age 61.2, range 32--85 years) patients suffering from NSCLC were submitted to pneumonectomy (n = 89), bilobectomy (n = 19) and lobectomy (n = 90). A rather strict protocol was used as a transfusion strategy. The transfusion requirements were analyzed and seven parameters (gender, age > 65, preoperative Hb < 11.5 g/dl, chest wall resection, history of previous thoracotomy, pneumonectomy and total blood loss) were statistically evaluated by univariate and logistic regression analysis. Subsequently, according to the perioperative Hb level during the first 48 h, patients were divided into group A (n = 49, Hb = 8.5--10) and group B (n = 149, Hb > 10) with a view to estimate the risks of elective perioperative anaemia. Groups were comparable in terms of age, sex, type of operation performed, preoperative Hb, creatinine level, FEV1, arterial blood gases and history of heart disease. RESULTS: The overall transfusion rate was 16%. Univariate analysis revealed that preoperative Hb < 11.5 g/dl (P < 0.01) and total blood loss (P < 0.0001) were associated with increased need for transfusion, but only the total blood loss was identified as an independent variable in multivariate analysis. Statistical analysis between groups A and B showed no significant difference regarding postoperative morbidity and mortality: atelectasis (3 vs. 6), chest infection (2 vs. 9), sputum retention requiring bronchoscopy (5 vs. 12), admission to intensive care unit (5 vs. 7), ARDS (0 vs. 3), postoperative hospital stay (7.7 +/- 2.6 vs. 9.1 +/- 3.8 days) and deaths (1 vs. 3). CONCLUSIONS: The use of a strict transfusion strategy could help in reducing overall blood transfusion. Furthermore, a perioperative Hb of 8.5--10 g/dl could be considered safe in elective lung resections for carcinoma.     

Preoperative predictors for allogenic blood transfusion in hip and knee arthroplasty for rheumatoid arthritis

Introduction

To identify the preoperative predictors of requirement for postoperative allogenic blood transfusion following hip and knee joint arthroplasty.

Materials and methods

We analysed the retrospective data on patients with rheumatoid arthritis who had undergone either total hip or knee arthroplasty at a single university teaching hospital. Factors of age, sex, procedure type, preoperative haemoglobin, blood transfusion data, comorbidities and body mass index were investigated for association with postoperative allogenic blood after hip or knee arthroplasty.

Results

Three hundred and forty nine cases of patients with rheumatoid arthritis were reviewed. 21 % (n = 72) required allogenic blood transfusion. The only significant predictive preoperative factors associated with postoperative blood transfusion were a low preoperative haemoglobin (Hb) level (p < 0.001), procedure of total hip arthroplasty (p = 0.008), a previous history of myocardial infarction (p = 0.038) and previous allogenic blood transfusion (p = 0.03). A preoperative haemoglobin <120 g/l was associated with a tenfold increase in transfusion requirement. All patients with a preoperative Hb level <90 g/l were transfused.

Conclusions

The ability to identify those within this high-risk group who are likely to receive blood transfusion allows for an informed, appropriate and cost effective approach to blood management strategies.     

Perioperativer Einsatz von rhEPO bei Angehörigen der Glaubensgemeinschaft „Zeugen Jehovas“

Erythropoietin, the hematopoietic growth factor, is synthesised in the kidneys and liver and regulates red blood cell production. Within the last few years, recombinant DNA technology has produced synthetic erythropoietin (rhEPO). Some patients, especially Jehova's Witnesses, will not accept blood transfusion. The perioperative administration of rhEPO increases the patients' hematocrit (HCt) to a higher than physiological level. Methods and results. We report a case of a 66-year-old female Jehova's Witness who refused blood transfusions and responded favourably to rhEPO treatment. A total hip arthroplasty was planned. A pre-treatment hemoglobin level (Hb) of 13.7 g/dl and HCt of 43% were documented. After preoperative subcutaneous application of 5000 I.E. rhEPO three times per week and daily oral substitution of 300 mg ferrous sulfate over a period of 3 weeks, the Hb increased to 15.5 g/dl and the HCt to 49%. The operation was carried out after the ninth application of rhEPO. Postoperatively, the Hb concentration was 11.8 g/dl and the HCt 35%. Therefore, postoperative administration of rhEPO was not considered indicated. No side effects of rhEPO application were noted. The patient left hospital on the 10th postoperative day. Conclusions. The case report describes perioperative management using human rhEPO in Jehova's Witnesses. Treatment with rhEPO increases preoperative Hb levels to a point making it possible to compensate for operative blood loss. RhEPO combined with daily iron substitution may be useful in patients who refuse transfusion based on religious convictions.     

Conducta transfusional perioperatoria en la cirugía del cáncer gástrico: análisis del registro del grupo español EURECCA de cáncer esófago-gástrico

Introduction

This study evaluated allogenic packed red blood cell (aPRBC) transfusion rates in patients undergoing resection for gastric cancer and the implementation of blood-saving protocols (BSP).

Autologous blood transfusion following total knee arthroplasty: is it always necessary?

A retrospective study of 85 patients undergoing primary total knee replacement (TKR), who also received autologous blood transfusion (ABT) to compensate for the perioperative blood loss. In our series 16.4% of the patients needed allogenic blood transfusion. Of the remaining 83.4% only 49.5% received autologous transfusion. Autologous transfusion was withheld in 34.1% of cases either because the blood volume was inadequate or because the collection time exceeded the recommended time limit. The mean haemoglobin (Hb) level with or without autologous transfusion was 10 g, raising the question of the necessity of using autologous transfusion in primary total TKR.     

Tolerance to perioperative anemia. Mechanisms, influencing factors and limits

The expected cost explosion in transfusion medicine increases the socio-economic significance of specific institutional transfusion programs. In this context the estimated use of the patient's physiologic tolerance represents an integral part of any blood conservation concept. The present article summarizes the mechanisms, influencing factors and limits of this natural tolerance to anemia and deduces the indication for perioperative red blood cell transfusion. The current recommendations coincide to the effect that perioperative transfusion is unnecessary up to a Hb concentration of 10 g/dl (6.21 mmol/l) even in older patients with cardiopulmonary comorbidity and is only recommended in cases of Hb <6 g/dl (<3.72 mmol/l) in otherwise healthy subjects including pregnant women and children. Critically ill patients with multiple trauma and sepsis do not seem to benefit from transfusions up to Hb concentrations >9 g/dl (>5.59 mmol/l). In cases of massive hemorrhaging and diffuse bleeding disorders the maintenance of a Hb concentration of 10 g/dl (6.21 mmol/l) seems to contribute to stabilization of coagulation.     

Tolerance to perioperative anemia. Mechanisms, influencing factors and limits

The expected cost explosion in transfusion medicine increases the socio-economic significance of specific institutional transfusion programs. In this context the estimated use of the patient's physiologic tolerance represents an integral part of any blood conservation concept. The present article summarizes the mechanisms, influencing factors and limits of this natural tolerance to anemia and deduces the indication for perioperative red blood cell transfusion. The current recommendations coincide to the effect that perioperative transfusion is unnecessary up to a Hb concentration of 10 g/dl (6.21 mmol/l) even in older patients with cardiopulmonary comorbidity and is only recommended in cases of Hb <6 g/dl (<3.72 mmol/l) in otherwise healthy subjects including pregnant women and children. Critically ill patients with multiple trauma and sepsis do not seem to benefit from transfusions up to Hb concentrations >9 g/dl (>5.59 mmol/l). In cases of massive hemorrhaging and diffuse bleeding disorders the maintenance of a Hb concentration of 10 g/dl (6.21 mmol/l) seems to contribute to stabilization of coagulation.     

Effectiveness of postoperative autologous blood transfusion after knee replacement surgery and influence of preoperative hemoglobin level

OBJECTIVE: To evaluate the effectiveness of postoperative autologous blood transfusion on reducing the need for allogenic transfusion during recovery from total knee arthroplasty until hospital discharge, and to determine whether effectiveness is related to preoperative hemoglobin level. MATERIAL AND METHODS: Retrospective study of patients undergoing surgery at Hospital Jerez de la Frontera, Spain, in 2003, assessing the association between postoperative autologous blood transfusion, preoperative hemoglobin, and allogenic transfusion requirements. RESULTS: A total of 107 patients were studied. Eighty-three received autologous blood transfusions after surgery and 15 (14.02%) required allogenic transfusion. The rate of allogenic transfusion was higher in association with hemoglobin levels exceeding 13 g x dL(-1) (P=0.003) and it was lower in patients who received autologous blood transfusions (P=0.046). In patients who received autologous transfusion, preoperative hemoglobin level and risk of allogenic transfusion were unrelated. When autologous transfusion was not given, allogenic transfusion risk was higher when hemoglobin concentration was less than 13 g x dL(-1) (P=0.0008). Autologous transfusion had a significant effect when hemoglobin level was less than 13 g x dL(-1) (P=0.002) but did not affect the rate of transfusion when hemoglobin was 13 g x dL(-1) or more. CONCLUSIONS: Autologous blood transfusion is effective for reducing the need for allogenic transfusion after knee replacement surgery, particulary when a patient's hemoglobin level is less than 13 g x dL(-1).     

Perioperative blood management practices in elective orthopaedic surgery

Concern about the cost and safety of allogenic blood transfusion, including the risk of viral infection and immunosuppression, has led to refinements in and new approaches to blood conservation, including the development of transfusion practice standards and improvements in surgical practice. Preoperative autologous blood collection, the use of hemostatic agents, perioperative blood salvage, and the use of recombinant human erythropoietin (epoetin alfa) to stimulate erythropoiesis have contributed to decreased use of allogenic blood services. Development of appropriate blood management strategies to help reduce or eliminate exposure to allogenic blood requires a preoperative assessment of the likelihood of transfusion and of the risks as well as costs associated with conservation and replacement options. The informed selection of alternatives based on preoperative assessment of hematologic status, estimated blood loss, and sources for blood replacement may enhance blood management practices in major elective orthopaedic surgery.     

Minimizing allogeneic blood transfusion in knee prosthesis implantation

The goal of blood management in orthopedic and trauma surgery is to minimize exposure to allogenic blood transfusion in elective surgical procedures. Pre-, intra- and postoperative techniques are available. In a retrospective study at our department we could show, that postoperative reinfusion in primary knee arthroplasty is an effective way to avoid allogenic blood transfusion. We evaluated two groups of totally 40 patients. Group I (20 patients) underwent collection of postoperative drainage blood and reinfusion (blood conservation system, CBC II ConstaVac, Stryker^® instruments), group II (20 patients) was treated without postoperative reinfusion. Group II required per patient 1,3 units of allogenic blood (totally 26 units), group I needed only 0,25 units of allogenic blood per patient (totally 5 units) by using the same guidelines for transfusion in both groups. There were similar preoperative and postoperativ hemoglobin and hematocrit levels in both groups. We recommend the use of postoperative reinfusion in addition with other blood saving techniques to reduce allogenic blood transfusion in primary knee arthroplasty.     

Blutungsprobleme in der offenen Herzchirurgie

Across centers, transfusion can vary eightfold for the same mediastinal drainage after adult cardiac operations. Excessive blood drainage resulting in increased transfusions occurs in 29% of patients. Various strategies have been proposed to decrease bleeding and allogenic transfusion requirements in the perioperative period of heart surgery. Blood conservation methods were reviewed critically. Avoidance of preoperative anemia, tolerance of low hemoglobin concentrations, the use of autologous blood, and adherence to a strict transfusion protocol will reduce the use of allogenic transfusions. Perioperatively, maintenance of normothermia contributes to improved hemostasis.     

Hemostatic Markers as Predictors of Massive Blood Transfusion in Orthotopic Liver Transplantation

BackgroundThe aim of this study was to determine which standard preoperative laboratory results correlate to intraoperative transfusion requirement during orthotopic liver transplantation (OLT).Materials and MethodsWe retrospectively analyzed data from 305 adult patients who underwent OLT between 2009 and 2013 using laboratory results: International Normalization Ratio, platelet count, fibrinogen, and hemoglobin and total blood transfusion requirements (group L ≤ 1 L, group M > 1 L). All statistical analyses were conducted using the Statistical Package for Social Sciences software (IBM Corp. Released 2012. IBM SPSS for Windows, Version 21.0; IBM Corp., Armonk, NY, United States).ResultsWe found a positive correlation with hemoglobin and fibrinogen using multivariate analysis (P < .001). The receiver operating characteristic analysis in favor of total blood replacement > 1 L has shown a correlation with fibrinogen (cut-off value of 2.3 g/L, sensitivity of 85.8%, and specificity of 37.4%) and hemoglobin (cut-off 111 g/L, sensitivity of 69.9%, and specificity of 71.6%).Discussion and ConclusionThis study has confirmed that preoperative fibrinogen and hemoglobin level, but not International Normalization Ratio and platelet count, are indicators of potential massive perioperative blood loss during OLT and that within our patient cohort a cut-off fibrinogen value of 2.3 g/L and Hb level of 110g/L can predict a blood replacement of >1 L.