The PRICE Trial: Phlebotomy Resulting in Controlled Hypovolemia to Prevent Blood Loss in Major Hepatic Resections
Trial Snapshot
- Phase
- Not Applicable
- Status
- Completed
- Enrollment
- 62
- Locations
- 1
- Primary Endpoint
- Total Intraoperative Blood Loss, by Measurement of Change in Hemoglobin Levels
Study Overview
Brief Summary
Major liver resection is associated with substantial intraoperative blood loss. Blood loss in elective liver surgery is a significant factor of perioperative morbidity and mortality, as well as possibly long-term oncologic outcome. The purpose of this study is to use whole blood phlebotomy to decrease the central venous pressure, resulting in a state of relative hypovolemia. It is hypothesized that this intervention will lead to a decrease in blood loss at the time of liver resection.
Detailed Description
Major liver resection is associated with significant intraoperative blood loss. Blood loss in elective liver surgery is a key determinant of perioperative morbidity and mortality, as well as possibly long-term oncologic outcome. Whole blood phlebotomy is a simple intervention, whose aim is to decrease the central venous pressure yielding a state of relative hypovolemia and thus lead to decreased blood loss. Small studies, mostly from the liver transplant literature, would suggest that phlebotomy with controlled hypovolemia can result in decreased blood loss and blood transfusion. Since blood loss is an important issue in liver surgery, and the benefits of phlebotomy and controlled hypovolemia are unknown in liver resection patients, a rigorously conducted trial in a representative population of patients undergoing liver resection is warranted, and feasible. In this proposal, it is hypothesized that by the use of phlebotomy and controlled hypovolemia, it is possible to decrease blood loss and blood transfusions. To test this hypothesis the investigators plan to randomly allocate participants to phlebotomy plus standard of care or to standard of care. Participants will be those patients undergoing elective major liver resection at the Ottawa Hospital for any indication. The primary outcome will be intraoperative blood loss. Secondary outcomes will include transfusion requirements, perioperative morbidity and mortality, safety, physiologic parameters, and feasibility elements. A total of 62 patients will be randomized. The efficacy of phlebotomy in terms of blood loss prevention will be assessed.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Prevention
- Masking
- Triple (Participant, Investigator, Outcomes Assessor)
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Any patient being considered for a major elective liver resection will be considered for trial enrollment. Patients who are undergoing a concurrent additional abdominal or thoracic procedure (eg. colonic resection) will also be included.
Exclusion Criteria
- •Age <18 years
- •Pregnancy
- •Refusal of blood products
- •Active cardiac conditions: unstable coronary syndromes, decompensated heart failure (NYHA functional class IV; worsening or new-onset heart failure), significant arrhythmias, severe valvular disease
- •History of significant cerebrovascular disease
- •Renal dysfunction (patients with an estimated GFR <60 mL/min)
- •Abnormal coagulation parameters (INR >1.5 not on warfarin and/or platelets count <100 X109/L )
- •Evidence of hepatic metabolic disorder (bilirubin >35 umol/L)
- •Presence of active infection
- •Preoperative autologous blood donation
- •Hemoglobin <100 g/L
Arms & Interventions
Phlebotomy
For patients randomized to phlebotomy, the intervention will consist of the standard of care (low CVP surgery), plus whole blood phlebotomy. Blood will be collected in citrated whole blood collection bag.
Intervention: Phlebotomy (Procedure)
Phlebotomy
For patients randomized to phlebotomy, the intervention will consist of the standard of care (low CVP surgery), plus whole blood phlebotomy. Blood will be collected in citrated whole blood collection bag.
Intervention: Citrated whole blood collection bag (Device)
Control
Standard of care (low CVP surgery). In this arm, standard anesthesia will be maintained.
Outcomes
Primary Outcomes
Total Intraoperative Blood Loss, by Measurement of Change in Hemoglobin Levels
Time Frame: 1 week prior to surgery (hemoglobin level), and day two of post-op (hemoglobin again).
Intraoperative blood loss is notoriously difficult to measure. It is suggested that calculation of blood loss using preoperative and postoperative hemoglobin levels in most consistently accurate. In order to minimize the risk of bias associated with any one method of intraoperative measurement of blood loss, three methods will be used independently. In the operating room, all blood and fluid aspirated from the abdomen will be measured accurately using graduated suction containers. As well, the amount of irrigation fluid will be carefully monitored and recorded. Finally, the weight of all surgical sponges will be measured. This information will be used by the surgeon and anesthesiologist to independently visually estimate blood loss, as is commonly done in clinical practice. In parallel, intraoperative blood loss will also be calculated based on an equation.
Trial Feasibility
Time Frame: through study completion, an average of 2 years
Trial accrual
Secondary Outcomes
- Changes in Physiologic Parameters (CVP)(Will be measured in the operating room)
- Blood Product Transfusion Rates(Will be measured in the operating room and in the first postoperative week)
- Perioperative Morbidity (Dindo-Clavien Grade 3b of Higher) and Mortality(Postoperative setting up to 30 days following surgery)
- Change in Physiologic Parameters (Cardiac Index)(Will be measured in the operating room)