*Purpose: The aim of this study is to identify risk factors for massive intraoperative blood loss and transfusion in pediatric liver transplant recipients and describe its impact on graft survival, mortality, and hospital length of stay (LOS).

*Methods: We reviewed all primary pediatric liver transplants performed at our institution between September 2007 and September 2016. Data is presented as n (%) or median (interquartile range). Estimated blood loss (EBL) was standardized by weight. Massive intraoperative blood loss and massive intraoperative transfusion were defined as greater than the 85^th percentile of the cohort.

*Results: 250 transplants were performed during the study period. Median EBL was 9.8 (5.5-21.5) cc/kg and 85^th percentile was 34 cc/kg. 38 (15%) recipients had massive EBL. Median post-transplant LOS among those with massive EBL was 31.5 (15-58) days compared to 11 (7-21) days among those without massive EBL (p < 0.001). Upon backwards stepwise regression, technical variant graft (OR 2.71, 95% CI 1.02 to 7.24), operative time (OR 2.77, 95% CI 1.85 to 4.15), and transfusion of FFP, platelet, and/or cryoprecipitate (OR 4.98, 95% CI 1.98 to 12.54) were identified as significant independent risk factors for massive EBL, while being admitted from home (OR 0.25, 95% CI 0.097 to 0.664) was a significant protective factor against massive EBL. Median transfusion volume was 16 (6.9-28.8) cc/kg and 85^th percentile was 38 cc/kg. 37 (15%) recipients had massive transfusion. Patients with massive transfusion had a greater LOS, with a median LOS of 34 (14-59) days compared to 11 (7-21) days among patients who did not require massive transfusion (p=0.001). Upon backwards stepwise regression, recipient weight (OR 0.93, 95% CI 0.88 to 0.99), technical variant graft (OR 2.84, 95% CI 1.03 to 7.83), operative time (OR 2.04, 95% CI 1.40-2.96) and transfusion of FFP, platelets, and/or cryoprecipitate (OR 6.63, 95% CI 2.55 to 17.26) were significant independent risk factors for massive transfusion, while being admitted from home for transplantation (OR 0.22, 95% CI 0.88 to 0.99) was a significant protective factor against massive transfusion. Massive EBL and massive transfusion were not statistically significant for overall graft survival (HR 1.23, 95% CI 0.47 to 3.2 and HR 1.21, 95% CI 0.46 to 3.1, respectively). Massive transfusion was, however, a significant risk factor for 30-day graft loss (HR 2.995, 95% CI 1.02 to 8.76).

*Conclusions: Pediatric liver transplant recipients with massive EBL or massive transfusion had significantly longer LOS and increased 30-day graft loss in patients who required massive transfusion. We identified longer operative time and technical variant graft were significant independent risk factors for massive EBL and transfusion, while being admitted from home prior to transplantation was a protective factor. Recipient weight was an independent risk factor for massive transfusion, but not massive EBL.

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