Risk factors for massive blood transfusion in cytoreductive surgery: A multivariate analysis of 243 procedures

Background: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with peritoneal carcinomatosis (PC). This treatment modality is associated with high blood loss and often requires massive allogenic red blood cell transfusion (MABT). Our study is the first of its kind to evaluate the risk factors for intraoperative MABT in peritonectomy procedures. Methods: Two hundred and forty-three consecutive CRS and PIC procedures were evaluated. The associations between 17 preoperative and intraoperative risk factors and intraoperative MABT (≥6 units) were assessed by univariate and multivariate analysis. Results: One hundred and eighty-six (77%) procedures required intraoperative transfusion of packed red blood cells. Ninety-one procedures required MABT (37%). Multivariate analysis showed six significant risk factors for intraoperative MABT: operative length > 9 h (p < 0.001), preoperative hemoglobin < 125 g/l (p < 0.001), operation date prior to 2004 (p = 0.002), peritoneal cancer index ≥ 16 (p = 0.006), preoperative international normalized ratio (INR) ≥ 1.2 (p = 0.008), and number of peritonectomy procedures ≥ 4 (p = 0.021). Statistical analysis also revealed that MABT was associated with increased intensive care unit (ICU) (p < 0.001), high-dependency unit (HDU) (p = 0.020), and total hospital stay (p < 0.001) and with severe morbidity (p < 0.001). Conclusions: Patients with preoperative anemia, impaired coagulation profile or extensive tumor burden are at high risk of MABT. Appropriate blood conservation strategies should be adopted in these patients on the basis of their risk factors.