Large-volume fluid resuscitation is often required during liver transplantation (LT) to maintain haemodynamic stability, prevent critical anaemia and severe coagulopathy, and maintain oxygen delivery. The administration of extremely large volumes of crystalloids, colloids, blood products, and coagulation factors in LT remains unexplored. We investigated the prevalence of ultra-massive fluid transfusion (UMFT) in adult patients undergoing LT. We defined UMFT a priori as a total perioperative transfusion >20 litres of crystalloids, colloids, blood products, and coagulation factors that were administered intraoperatively and for the first 24-hours postoperatively.

After obtaining ethics approval (HREC/105884/Austin-2024), we conducted an observational study of adults (aged >18 years) undergoing orthotopic LT where a whole liver was taken from a deceased donor. We included consecutive transplants from November 2009 to April 2023. We included patients who received more than 20 litres of fluid intraoperatively and within 24 hours postoperatively. All surgeries were performed at Austin Health, Australia, which is home to Victoria’s Liver Transplant Unit. Postoperative surgical complications were defined by the Clavien-Dindo (CD) classification.

The key aim was to determine the prevalence of UMFT. Secondary aims were to determine if the volume of fluid transfused was associated with postoperative complications, mechanical ventilation hours, ICU and hospital length of stay (LOS), and mortality. In addition, we collected the following LT specific complications: graft non-function, long-term failure, bile leakage, hepatic artery/vein thrombosis, and liver abscess.

We evaluated the unadjusted relationship between complications and the volume of fluid transfused using correlation analysis and regression models. During the regression analysis, the results were adjusted with the following variables: age, body mass index, the Model for End Stage Liver Disease (MELD) score, preoperative prothrombin time, albumin, platelet, and haemoglobin levels, surgical technique and duration, and use of vasoactive medications.  

In total, 81/800 (10.1%) patients who underwent LT over the study period received an UMFT. Three patients (3.7%) underwent a combined liver-kidney transplant, and eight patients (9.9%) had a redo-transplant. 60.5% of patients were male; the average age was 54.2 years, and the median (IQR) MELD score was 20 (14‒26). The median (IQR; minimum-maximum) volume of UMFT was 36.8 litres (31.2‒48.7; 23.4 to 139.3 litres). The median total (IQR) transfusion units of packed red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate, and platelets were 15 (12–22), 7 (5–11), 20 (10–33), and 3 (2–5) units, respectively. Sixty-six patients (81.5%) had a postoperative complication, and 34 patients (42.0%) had a severe complication (CD>IIIb).

For every litre of fluid transfused, ventilation time, ICU and hospital LOS increased by 6.4 hours (95%CI 3.1–9.7, P=0.001), 0.5 days (95%CI 0.2–0.8, P=0.001), and 0.84 days (95%CI 0.4–1.3, P<0.001), respectively. In addition, for each unit of RBC transfused, the ventilation times, ICU and hospital LOS increased by 16.7 hours (95%CI 9.6–23.8, P<0.001), 1.3 days (95%CI 0.7–1.8, P<0.001), and 2.3 days (95%CI 1.3–3.2, P<0.001) respectively. We observed no significant association between the volume of transfused fluid, complications, and mortality at 30 days, 1 year, and 5 years.

Our findings indicate that 1 in 10 adult liver transplant recipients undergoing orthotopic liver transplantation from a deceased donor required an UMFT. Both UMFT and the number of RBCs transfused were associated with increased mechanical ventilation time, and increased ICU and hospital LOS. However, our findings support that the appropriate use of large volume resuscitation and blood component therapy in adult patients with critical bleeding during LT is not an independent risk factor for developing multi-organ failure, complications, and short-term and medium-term (5-year) mortality. Further research into fluid transfusion in liver transplantation surgery is required for predictive risk models for UMFT.

Conflicts of interest: None