The Takeaway

Tranexamic acid (TXA) can help reduce blood transfusions in hepatectomy without added risk, although more studies are needed to refine dosing and safety profiles.

Study Design

• Randomized, double-blind, controlled study
• 119 patients who underwent hepatectomy, between 18 and 70 years, ASA status I–III, and Child-Pugh class A or B
• Exclusion criteria: patients who were obese (BMI > 32 kg/m²); patients with severe cardiopulmonary dysfunction; patients with a history of myocardial infarction or cerebral infarction; patients with renal insufficiency, coagulation dysfunction, pre-existing thromboembolism, tranexamic acid allergy, or contraindications
• Intervention arm included an intravenous infusion of 10 mg/kg of TXA 30 min before surgery, and continuously at 1 mg/(kg.h) until the end of surgery
• Primary outcomes were intraoperative blood loss, blood transfusion rate, intraperitoneal drainage at 24 h after surgery, and the occurrence of compound bleeding within 30 days

Physiology Rewind

Why Controlled Low Central Venous Pressure (CLCVP)?

Liver surgery carries a high risk of bleeding because the liver has a dense vascular network with low resistance and high blood flow. A major contributor to bleeding is hepatic venous congestion, which results from high central venous pressure (CVP). High CVP leads to increased backflow from the hepatic veins, making it harder for surgeons to achieve hemostasis. By maintaining low CVP (≤5 mmHg), hepatic venous pressure is reduced, leading to less blood pooling and lower intraoperative blood loss. However, lowering CVP too much can compromise venous return and cardiac output, so anesthetic management must balance volume status, vasoactive support, and positioning (e.g., head-up tilt) to optimize perfusion while keeping CVP low.

Why TXA?

Tranexamic acid is an antifibrinolytic drug that blocks plasmin from breaking down fibrin clots. In major surgeries like hepatectomy, fibrinolysis is upregulated due to surgical trauma, extensive tissue damage, and activation of coagulation pathways. This increases the risk of excessive bleeding despite normal clot formation.

TXA helps by stabilizing clots and reducing intraoperative blood loss. However, concerns exist about thrombotic complications, especially in patients with underlying cardiovascular disease. The study found that TXA use in hepatectomy under low central venous pressure did not significantly increase thrombotic events, supporting its safety in this setting.

Excerpts

The liver has a complex anatomy with abundant blood supply, and the portal vein delivers 75% of the blood flow into the liver. Hepatectomy carries a considerable risk of bleeding during the procedure, and bleeding can inhibit hepatocyte regeneration, leading to liver injury and even liver failure.

23–26% of patients undergoing hepatectomy require intraoperative red blood cell transfusion and this can compromise short-term prognostic outcomes and increase the 30-day mortality.

Blood loss and blood transfusion directly influence postoperative complications and prognosis.

Patients undergoing hepatectomy can have impaired liver function, underlying coagulopathy, direct liver injury from surgery, intraoperative hypothermia, acidosis, and a systemic inflammatory response, which can result in hyperfibrinolysis and increased bleeding.

it has been found that reducing CVP with nitroglycerin and esmolol provides the best surgical field under the same fluid-restriction strategy, because 60 to 80% of the blood supply is from the portal vein, after clamping the hepatic artery, which supplies 20 to 40% of the blood, the effect of arterial pressure on mitigating hepatic surgical field bleeding decreased

The use of a combination of TXA and CLCVP in hepatectomy can reduce intraoperative blood loss and the need for blood transfusions to a significant extent. However, identifying the duration and optimum dose of TXA combined with CLCVP are still in the exploratory stage.

TXA did not reduce intraoperative bleeding compared to the control group. However, TXA significantly decreased the requirement for intraoperative blood transfusions and reduced the intraperitoneal drainage volume 24 h post-surgery.

while no difference in blood loss was observed between groups, the dose of TXA used in this study was relatively low. Higher doses, as shown in other surgical studies, may offer greater reductions in transfusion rates without increasing adverse events, but further research is needed to determine the optimal TXA dosing strategy for hepatectomy under CLCVP

Citation

Luo JY, Zhou C, Shi SX, Wei QX, Chen Y, Ouyang J, Si YY. Use of tranexamic acid in hepatectomy under controlled low central venous pressure: a randomized controlled study. BMC Anesthesiol. 2025 Feb 21;25(1):94. doi: 10.1186/s12871-025-02935-0. PMID: 39984870; PMCID: PMC11843753.

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