Controlled low central venous pressure to reduce blood loss in liver resection: A narrative review
Main Article Content
Abstract
Blood loss control during hepatectomy affects clinical outcomes. The strategy of maintaining low central venous pressure (CVP) is implemented to reduce bleeding by decreasing sinusoidal hydrostatic pressure in the liver. This systematic review consolidates methods for CVP reduction to control blood loss during hepatectomy. A narrative review was conducted through PubMed/MEDLINE search up to February 2026. Keywords: low CVP, hepatectomy, blood loss. CVP-reduction measures are categorized into two groups. The absolute hypovolemia group (fluid restriction, diuretics, volume-reducing phlebotomy) achieves target CVP rapidly and effectively reduces blood loss but may prolong hospital length of stay. The fluid redistribution group using vasodilators achieves success rates of 85 – 92%; Milrinone appears superior to Nitroglycerin due to its dual vasodilatory and inotropic effects. Adjusting ventilation reduces CVP effectively but should avoid hypercapnia-induced hepatic vasodilation
Article Details
Keywords
Hepatectomy, low central venous pressure, vasodilators, perioperative blood loss
References
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7. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
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12. Lapisatepun W, Chotirosniramit A, Junrungsee S, et al. Impact of Hypovolemic Phlebotomy With Low Central Venous Pressure on Intraoperative Blood Loss in Open Liver Resection: A Double-Blind Randomized Controlled Trial. Ann Surg. 2026; 283(2): 203-211. doi:10.1097/SLA.0000000000006760.
13. Zatloukal J, Pradl R, Kletecka J, Skalicky T, Liska V, Benes J. Comparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial. Minerva Anestesiol. 2017; 83(10): 1051-1060. doi:10.23736/S0375-9393.17.11824-9.
14. Jongerius IM, Mungroop TH, Uz Z, et al. Goal-directed fluid therapy vs. low central venous pressure during major open liver resections (GALILEO): a surgeon- and patient-blinded randomized controlled trial. HPB. 2021; 23(10): 1578-1585. doi:10.1016/j.hpb.2021.03.013.
15. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
16. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol WJG. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
17. Yang P, Gao S, Chen X, Xiong W, Hai B, Huang X. Milrinone is better choice for controlled low central venous pressure during hepatectomy: A randomized, controlled trial comparing with nitroglycerin. Int J Surg. 2021; 94:106080. doi:10.1016/j.ijsu.2021.106080.
18. Lv H, Jiang X, Huang X, et al. Nitroglycerin versus milrinone for low central venous pressure in patients undergoing laparoscopic hepatectomy: a double-blinded randomized controlled trial. BMC Anesthesiol. 2024; 24(1): 244. doi:10.1186/s12871-024-02631-5.
19. Vincenzi P, et al. Nitroglycerin infusion for controlled low central venous pressure in laparoscopic liver resection: a dose-finding and safety study. Surgeries. 2019; 14(2): 112-120 - Google Search. Accessed May 29, 2026.
20. Hasegawa K, Takayama T, Orii R, et al. Effect of hypoventilation on bleeding during hepatic resection: a randomized controlled trial. Arch Surg. 2002; 137(3): 311-315. doi:10.1001/archsurg.137.3.311.
21. Iguchi T, Ikegami T, Fujiyoshi T, Yoshizumi T, Shirabe K, Maehara Y. Low Positive Airway Pressure without Positive End-Expiratory Pressure Decreases Blood Loss during Hepatectomy in Living Liver Donors. Dig Surg. 2017; 34(3): 192-196. doi:10.1159/000447755.
22. Redondo FJ, Padilla D, Villazala R, Villaeiro P, Baladron V, Bejerano N. Global end-diastolic volume could be more appropiate to reduce intraoperative bleeding than central venous pressure during major liver transection. Anestezjol Intensywna Ter. 2017; 49(2): 100-105. doi:10.5603/AIT.2017.0030.
23. Ratti F, Cipriani F, Reineke R, et al. Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial. HPB. 2016; 18(2): 136-144. doi:10.1016/j.hpb.2015.09.005.
24. Choi SS, Jun IG, Cho SS, Kim SK, Hwang GS, Kim YK. Effect of stroke volume variation-directed fluid management on blood loss during living-donor right hepatectomy: a randomised controlled study. Anaesthesia. 2015; 70(11): 1250-1258. doi:10.1111/anae.13155.
25. Chirnoaga D, Coeckelenbergh S, Ickx B, et al. Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: A pilot randomised controlled trial. Eur J Anaesthesiol. 2022; 39(4): 324-332. doi:10.1097/EJA.0000000000001615.
26. Coeckelenbergh S, Soucy-Proulx M, Van der Linden P, et al. Restrictive versus Decision Support Guided Fluid Therapy during Major Hepatic Resection Surgery: A Randomized Controlled Trial. Anesthesiology. 2024; 141(5): 881-890. doi:10.1097/ALN.0000000000005175.
2. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev. 2007; 21(6): 327-348. doi:10.1016/j.blre.2007.07.003.
3. Simillis C, Li T, Vaughan J, Becker LA, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev. 2014; (4): CD010683. doi:10.1002/14651858.CD010683.pub2.
4. Karanicolas PJ, Lin Y, McCluskey SA, et al. Tranexamic Acid in Patients Undergoing Liver Resection: The HeLiX Randomized Clinical Trial. JAMA. 2024; 332(13): 1080-1089. doi:10.1001/jama.2024.11783.
5. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg. 1998; 85(8): 1058-1060. doi:10.1046/j.1365-2168.1998.00795.x.
6. Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg. 1998; 187(6): 620-625. doi:10.1016/s1072-7515(98)00240-3.
7. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
8. Lin CX, Guo Y, Lau WY, et al. Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int HBPD INT. 2013; 12(5): 520-524. doi:10.1016/s1499-3872(13)60082-x.
9. Pan YX, Wang JC, Lu XY, et al. Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy: A double-blind randomized clinical trial. Surgery. 2020;167(6):933-941. doi:10.1016/j.surg.2020.02.004
10. Erkoç SK, Kırımker EO, Büyük S, et al. Reducing Risk for Acute Kidney Injury After Living Donor Hepatectomy by Protocolized Fluid Restriction: Single-Center Experience. Transplant Proc. 2022; 54(8): 2243-2247. doi:10.1016/j.transproceed.2022.08.006.
11. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
12. Lapisatepun W, Chotirosniramit A, Junrungsee S, et al. Impact of Hypovolemic Phlebotomy With Low Central Venous Pressure on Intraoperative Blood Loss in Open Liver Resection: A Double-Blind Randomized Controlled Trial. Ann Surg. 2026; 283(2): 203-211. doi:10.1097/SLA.0000000000006760.
13. Zatloukal J, Pradl R, Kletecka J, Skalicky T, Liska V, Benes J. Comparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial. Minerva Anestesiol. 2017; 83(10): 1051-1060. doi:10.23736/S0375-9393.17.11824-9.
14. Jongerius IM, Mungroop TH, Uz Z, et al. Goal-directed fluid therapy vs. low central venous pressure during major open liver resections (GALILEO): a surgeon- and patient-blinded randomized controlled trial. HPB. 2021; 23(10): 1578-1585. doi:10.1016/j.hpb.2021.03.013.
15. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
16. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol WJG. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
17. Yang P, Gao S, Chen X, Xiong W, Hai B, Huang X. Milrinone is better choice for controlled low central venous pressure during hepatectomy: A randomized, controlled trial comparing with nitroglycerin. Int J Surg. 2021; 94:106080. doi:10.1016/j.ijsu.2021.106080.
18. Lv H, Jiang X, Huang X, et al. Nitroglycerin versus milrinone for low central venous pressure in patients undergoing laparoscopic hepatectomy: a double-blinded randomized controlled trial. BMC Anesthesiol. 2024; 24(1): 244. doi:10.1186/s12871-024-02631-5.
19. Vincenzi P, et al. Nitroglycerin infusion for controlled low central venous pressure in laparoscopic liver resection: a dose-finding and safety study. Surgeries. 2019; 14(2): 112-120 - Google Search. Accessed May 29, 2026.
20. Hasegawa K, Takayama T, Orii R, et al. Effect of hypoventilation on bleeding during hepatic resection: a randomized controlled trial. Arch Surg. 2002; 137(3): 311-315. doi:10.1001/archsurg.137.3.311.
21. Iguchi T, Ikegami T, Fujiyoshi T, Yoshizumi T, Shirabe K, Maehara Y. Low Positive Airway Pressure without Positive End-Expiratory Pressure Decreases Blood Loss during Hepatectomy in Living Liver Donors. Dig Surg. 2017; 34(3): 192-196. doi:10.1159/000447755.
22. Redondo FJ, Padilla D, Villazala R, Villaeiro P, Baladron V, Bejerano N. Global end-diastolic volume could be more appropiate to reduce intraoperative bleeding than central venous pressure during major liver transection. Anestezjol Intensywna Ter. 2017; 49(2): 100-105. doi:10.5603/AIT.2017.0030.
23. Ratti F, Cipriani F, Reineke R, et al. Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial. HPB. 2016; 18(2): 136-144. doi:10.1016/j.hpb.2015.09.005.
24. Choi SS, Jun IG, Cho SS, Kim SK, Hwang GS, Kim YK. Effect of stroke volume variation-directed fluid management on blood loss during living-donor right hepatectomy: a randomised controlled study. Anaesthesia. 2015; 70(11): 1250-1258. doi:10.1111/anae.13155.
25. Chirnoaga D, Coeckelenbergh S, Ickx B, et al. Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: A pilot randomised controlled trial. Eur J Anaesthesiol. 2022; 39(4): 324-332. doi:10.1097/EJA.0000000000001615.
26. Coeckelenbergh S, Soucy-Proulx M, Van der Linden P, et al. Restrictive versus Decision Support Guided Fluid Therapy during Major Hepatic Resection Surgery: A Randomized Controlled Trial. Anesthesiology. 2024; 141(5): 881-890. doi:10.1097/ALN.0000000000005175.