Bleeding Management During Hepatectomy

The presence of cirrhosis, especially Child-Turcotte-Pugh class C, significantly increases bleeding risk during hepatectomy, according to the Journal of Hepatology 3
Acute kidney injury increases bleeding risk, particularly in patients with acute-on-chronic liver failure, as reported by the Journal of Hepatology 3
Hypofibrinogenemia has been identified as an independent predictor of bleeding in patients with acute-on-chronic liver failure, according to the Journal of Hepatology 3

Preoperative Assessment and Management

Laboratory evaluation of hemostasis with the aim of predicting post-procedural bleeding is not indicated for low-risk procedures, with a Level of Evidence 4 and strong recommendation from the Journal of Hepatology 4
For high-risk procedures, laboratory tests may serve to provide baseline status but are generally not predictive of bleeding risk, as stated by the Journal of Hepatology 3

Low central venous pressure (below 5 cm H2O) with close monitoring is associated with decreased blood loss during liver resection, according to the World Journal of Emergency Surgery 1
Primary surgical intention should be to control hemorrhage, control bile leak, and institute intensive resuscitation as soon as possible, with a Grade of Recommendation 2B from the World Journal of Emergency Surgery 5
Angioembolization is a useful tool in case of persistent arterial bleeding, with a Grade of Recommendation 2A from the World Journal of Emergency Surgery 5

Excessive administration of crystalloids should be avoided as much as blood loss during liver surgery, as recommended by the World Journal of Emergency Surgery 1
Balanced crystalloids (e.g., Ringer's lactate) are recommended as maintenance fluid and colloids as volume expander (e.g., human albumin), according to the World Journal of Emergency Surgery 1
Restrictive transfusion strategy (transfusion with hemoglobin <7 g/dl with a target of 7-9 g/dl) is recommended to avoid increasing portal pressure, as suggested by Praxis Medical Insights 2

Patients with cirrhosis undergoing invasive procedures should be monitored for bleeding complications in the same way as patients without cirrhosis, with a Level of Evidence 3 and strong recommendation from the Journal of Hepatology 6
Early mobilization after liver surgery should be established from the operative day until hospital discharge, as recommended by the World Journal of Emergency Surgery 1