Cerebral effects and blood sparing efficiency of sodium nitroprusside-induced hypotension alone and in combination with acute normovolaemic haemodilution

The combined reduction of oxygen-carrying capacity and perfusionpressure during the combination of acute normovolaemic haemodilution(ANH) and controlled hypotension (CH) raises concerns of hypoperfusionand ischaemic injury to the brain. Forty-two patients undergoingradical prostatectomy were prospectively allocated to receiveCH induced by sodium nitroprusside (mean arterial pressure (MAP)50 mm Hg), a combination of CH+ANH (post-ANH haematocrit 29%;intraoperative MAP 50 mm Hg), or standard anaesthesia (control).Serum levels of the brain-originated proteins neuron-specificenolase (NSE) and protein S-100, blood loss, transfusion requirements,adverse effects, and postoperative recovery profile were comparedamong the three groups. Intraoperative blood loss in the CHgroup (mean (SD)) (788 (193) ml) and CH+ANH group (861 (184)ml) was significantly less than in the control group (1335 (460)ml). Significantly fewer total units of allogeneic packed redblood cells (PRBC) were transfused in the patients receivinghypotensive anaesthesia (CH, 3 units; CH+ANH, 2 units; control,17 units). There was no difference in immediate postoperativerecovery profile among the three groups as determined by theemergence from anaesthesia and time to discharge from the postanaesthesiacare unit. Serum S-100 protein concentrations increased significantlyin all groups from baseline to peak concentrations 2 h postoperatively(CH 0.25 (0.11) µg litre^–1; CH+ANH 0.31 (0.12) µglitre^–1; control 0.31 (0.10) µg litre^–1).A return to baseline values was seen within 24 h postoperativelyin all patients. No changes in NSE concentrations were seen.Our observations suggest that CH and CH+ANH were effective inreducing blood loss and transfusion requirements in patientsundergoing radical prostatectomy. Increased serum S-100 proteinconcentrations imply a disturbance in astroglial cell membraneintegrity and an increased endothelial permeability of the blood–brainbarrier. There were no associations between serum S-100 proteinor NSE and adverse cognitive effects. Further work needs tobe done to determine the prognostic importance of S-100 proteinand NSE as surrogate variables of postoperative cerebral complications. Br J Anaesth 2001; 87: 699–705     

Intraoperative Low-volume Acute Normovolemic Hemodilution in Adult Open-heart Surgery

Background: Recently, various studies have questioned the efficacy of intraoperative acute normovolemic hemodilution (ANH) in reducing bleeding and the need for allogeneic transfusions in cardiac surgery. The aim of the present study was to reevaluate the effects of a low-volume ANH in elective, adult open-heart surgery.

Methods: Two hundred four consecutive adult patients undergoing cardiac surgery were prospectively randomized in a nonblinded manner into two groups: ANH group (103 patients), where 5-8 ml/kg of blood was withdrawn before systemic heparinization and replaced with colloid solutions, and a control group, where no hemodilution was performed (101 patients). Procedures included single and multiple valve surgery, aortic root surgery, coronary surgery combined with valve surgery, or partial left ventriculectomy. The purpose of the study was to evaluate the efficacy of ANH in reducing the need for allogeneic blood components. Routine hematochemical evaluations, perioperative blood loss, major complications, and outcomes were also recorded.

Results: No differences were found between the groups regarding demographics, baseline hematochemical data, and operative characteristics. There was no difference in the amount of transfusions of packed red cells, fresh frozen plasma, platelet concentrates, total number of patients transfused (control group, 36%vs. ANH group, 34.3%;P = 0.88), and amount of postoperative bleeding (control group, 412 ml [313-552 ml]vs. ANH group, 374 ml [255-704 ml]) (median [25th-75th percentiles]);P = 0.94. Further, perioperative complications, postoperative hematochemical data, and outcomes were not different.     

Intraoperative low-volume acute normovolemic hemodilution in adult open-heart surgery

BACKGROUND: Recently, various studies have questioned the efficacy of intraoperative acute normovolemic hemodilution (ANH) in reducing bleeding and the need for allogeneic transfusions in cardiac surgery. The aim of the present study was to reevaluate the effects of a low-volume ANH in elective, adult open-heart surgery. METHODS: Two hundred four consecutive adult patients undergoing cardiac surgery were prospectively randomized in a nonblinded manner into two groups: ANH group (103 patients), where 5-8 ml/kg of blood was withdrawn before systemic heparinization and replaced with colloid solutions, and a control group, where no hemodilution was performed (101 patients). Procedures included single and multiple valve surgery, aortic root surgery, coronary surgery combined with valve surgery, or partial left ventriculectomy. The purpose of the study was to evaluate the efficacy of ANH in reducing the need for allogeneic blood components. Routine hematochemical evaluations, perioperative blood loss, major complications, and outcomes were also recorded. RESULTS: No differences were found between the groups regarding demographics, baseline hematochemical data, and operative characteristics. There was no difference in the amount of transfusions of packed red cells, fresh frozen plasma, platelet concentrates, total number of patients transfused (control group, 36% vs. ANH group, 34.3%; P = 0.88), and amount of postoperative bleeding (control group, 412 ml [313-552 ml] vs. ANH group, 374 ml [255-704 ml]) (median [25th-75th percentiles]); P = 0.94. Further, perioperative complications, postoperative hematochemical data, and outcomes were not different. CONCLUSIONS: In patients undergoing elective open-heart surgery, low-volume ANH showed lack of efficacy in reducing the need for allogeneic transfusions and postoperative bleeding.     

A simple mathematical approach to calculate blood loss in radical prostatectomy

INTRODUCTION: The aim of this study was to apply a simple mathematical approach to calculate blood loss in 126 patients undergoing radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Perioperative red blood cell loss (RBCL) was estimated by adding the difference in circulating red blood cells from before to after surgery to the allogeneic red blood cells transfused in the same period. RESULTS: Mean preoperative hematocrit was 45 +/- 4% and mean perioperative RBCL was 574 +/- 297 ml, corresponding to a mean equivalent whole blood loss (WBL) of 1,479 +/- 831 ml. Twenty of 126 patients (15.9%) received 42 units of allogeneic packed red blood cells (PRBC), for a mean of 2.1 +/- 1.2 U/patient. The transfusion rate was higher in patients with a preoperative hematocrit of 40% or less (45 vs. 13%, p = 0.014). CONCLUSIONS: Anatomical RRP is still associated with appreciable operative blood loss. Owing to the high preoperative hematocrit values, the allogeneic blood transfusion rate is low and the transfusion requirement of the majority of patients is limited to about 2 units of PRBC. Preoperative autologous blood augmentation strategies may not be routinely needed for patients with a basal hematocrit of >40%.     

Evaluation of autologous transfusion for radical prostatectomy

Forty-six radical prostatectomy patients in whom an autologous transfusion had been performed in our hospital were studied retrospectively. Preoperative autologous donation (PAD), erythropoietin (EPO) administration and acute normovolemic hemodilution (ANH) were used for autologous transfusion. Red blood cell volume lost during hospitalization was calculated as 1329 +/- 493 ml. Red blood cell volume saved by PAD and ANH were calculated as 470 +/- 33 ml and 301 +/- 90 ml, respectively. Three patients made use of allogeneic blood transfusion. Radical prostatectomy can be performed using PAD, EPO and ANH without allogeneic transfusion.     

A Prospective Randomized Comparison of Three Blood Conservation Strategies for Radical Prostatectomy

Background: Preoperative autologous blood donation is a standard of care for elective surgical procedures requiring transfusion. The authors evaluated the efficacy of alternative blood-conservation strategies including preoperative recombinant human erythropoietin (rHuEPO) therapy and acute normovolemic hemodilution (ANH) in radical retropubic prostatectomy patients.

Methods: Seventy-nine patients were prospectively randomized to preoperative autologous donation (3 U autologous blood); rHuEPO plus ANH (preoperative subcutaneous administration of 600 U/kg rHuEPO at 21 and 14 days before surgery and 300 U/kg on day of surgery followed by ANH in the operating room); or ANH (blinded, placebo injections per the rHuEPO regimen listed previously). Transfusion outcomes, perioperative hematocrit levels, postoperative outcomes, and blood-conservation costs were compared among the three groups.

Results: Baseline hematocrit levels were similar in all groups (43% +/- 2%). On the day of surgery hematocrit decreased to 34% +/- 4% in the preoperative autologous donation group (P < 0.001), increased to 47% +/- 2% in the rHuEPO plus ANH group (P < 0.001), and remained unchanged at 43% +/- 2% in the ANH group. Allogeneic blood exposure was similar in all groups. The rHuEPO plus ANH group had significantly higher hematocrit levels compared with the other groups throughout the hospitalization (P < 0.001). Average transfusion costs were significantly lower for ANH ($194 +/- $192) compared with preoperative autologous donation ($690 +/- $128; P < 0.001) or rHuEPO plus ANH ($1,393 +/- $204, P < 0.001).     

Acute normovolemic hemodilution for radical prostatectomy: Can it replace preoperative autologous blood transfusion?

BACKGROUND: Although preoperative autologous blood donation (PAD) is accepted as a standard of care for radical prostatectomy, it is costly, time-consuming and has risks associated with blood storage. Acute normovolemic hemodilution (ANH) is reported to be less expensive and to preserve blood components more effectively than PAD. In the present study, the efficacy and safety of these two autologous blood-collection techniques were compared. METHODS: The study included 16 consecutive patients scheduled for radical prostatectomy. The first eight patients underwent conventional preoperative autologous blood donation of 400 mL 1 week before the operation (PAD group) and the second eight patients underwent acute normovolemic hemodilution followed by immediate operation (ANH group). All blood collected was transfused in the perioperative period. Preoperative and postoperative hematocrit levels in these two groups were compared. RESULTS: There were no differences in preoperative hematocrit, time of operation or operative blood loss between the two groups. In the ANH group, 1080 +/- 160 mL of blood were collected. The postoperative hematocrit level did not differ significantly between the groups. No patient in either group received allogeneic blood transfusion or experienced an adverse event directly related to blood transfusion. CONCLUSION: The two blood-conservation strategies resulted in similar postoperative hematologic outcomes. Given its advantages, which include lower cost, lower risk and higher convenience, ANH is one of the procedures that may replace conventional PAD for use in radical prostatectomy.     

The use of acute normovolemic hemodilution in patients undergoing cardiac surgery

Avoiding allogeneic blood transfusion during cardiac surgery and during the post-operative period is of great importance. Acute normovolemic hemodilution (ANH) is one of the options for blood salvage. We have prospectively analyzed 310 consecutive patients (pts) after different open heart procedures, operated on during April-May, 2000. ANH was possible in 226 pts (73%) with hemoglobin level over 125 g/l and hematocrit over 36%. Of those, one unit of blood was withdrawn in 128 pts (70%), while two to five units of blood were taken in 68 pts (30%). Total number of autologous blood units taken was 296, for the average of 1.31 units/pt. Predictors of increased intra- and post-operative blood loss were hematocrit (Hct) <39% (76% vs. 24%, p<0.001), age over 65 (p=0.028), female sex (p=0.006), CPB duration over 90 min (63% vs. 37%; p<0.001) and preoperative left ventricular ejection fraction (LVEF) <35% (63% vs. 37%; p<0.001). All pts with the above-mentioned characteristics were in need for allogeneic blood transfusion. During their hospital stay, 142 pts did not get allogeneic blood (142/310, 46%), and all were in the ANH group (142/226, 62%).     

Is preoperative donation of autologous blood rational for radical retropubic prostatectomy?

PURPOSE: We investigated differences in the rate of homologous blood transfusion and the degree of anemia to determine whether it is rational to have patients donate autologous blood before radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed the charts of 221 consecutive men who underwent radical retropubic prostatectomy performed by 1 surgeon in a 14-month period. About half of the patients donated autologous blood preoperatively. We evaluated perioperative hemoglobin, and the rate of autologous and homologous transfusion. RESULTS: The groups did not significantly differ in terms of demographic data, co-morbid conditions, clinical variables or hospitalization. Preoperatively mean hemoglobin plus or minus standard deviation was 13.4 +/- 1 and 14.7 +/- 1 gm./dl. in patients who did and did not donate blood, while homologous transfusion was required in 1 (1%) and 4 (3.5%), respectively (p = 0. 18). At hospital discharge anemia was more prevalent in nondonors. Of the men who did versus did not donate blood hemoglobin was less than 10 and less than 9 gm./dl. in 8.4% versus 34% (p <0.0001), and 12.5% versus 0% (p <0.0004), respectively. CONCLUSIONS: Our retrospective review of a cohort of patients who underwent radical retropubic prostatectomy showed no difference in homologous blood transfusion based on preoperative autologous donation status. Autologous donors had lower hemoglobin preoperatively, a higher rate of transfused units and higher hemoglobin at hospital discharge. Preoperative donation of autologous blood may not decrease the need for homologous transfusion in healthy patients undergoing radical retropubic prostatectomy.     

Safety,efficacy and cost of intra-operative cell salvage during open radical prostatectomy

BackgroundWe aim to examine the safety and efficacy of intra-operative cell salvage (ICS) in radical prostatectomy.MethodsA retrospective cohort study was performed, enrolling consecutive patients undergoing open radical prostatectomy at two institutions during 01/01/18–31/12/19. Patients were grouped by ICS use. Primary outcomes were allogeneic transfusion rates, and biochemical recurrence (prostate specific antigen >0.2 mg/mL). Secondary outcomes were use of adjuvant therapies, Clavien-Dindo complications and transfusion-related cost (allogeneic transfusion + ICS setup + ICS reinfusion).ResultsIn total, 168 men were enrolled. Patients were grouped based on whether they received no blood conservation technique (126 men) or ICS (42 men). Groups were similar in median age, pre- and post-operative haemoglobin and length of stay. They also had similar post-operative tumour Gleason score, TNM-stage and positive surgical margin rates. Compared with controls, the ICS group had shorter follow up (336 vs. 225 days; P=0.003). The groups had similar rates of biochemical recurrence (17% vs. 14%; P=0.90), adjuvant therapy use (30% vs. 29%; P=0.85) and complications (14% vs. 19% patients; P=0.46). There was no metastatic progression or cancer-specific mortality in either group. Although a similar proportion of patients received allogenic transfusion (2.4% vs. 4.8%; P=0.33) and units of packed red blood cells (PRBC) (9 vs. 5 units), transfusion-related costs were higher amongst the ICS group (AUD $11,422 vs. $43,227).ConclusionsICS use in radical prostatectomy was not associated with altered rates of allogeneic transfusion, complications, biochemical recurrence or adjuvant or salvage therapies. Transfusion related costs were higher in the ICS group.     

A prospective randomized comparison of three blood conservation strategies for radical prostatectomy.

BACKGROUND: Preoperative autologous blood donation is a standard of care for elective surgical procedures requiring transfusion. The authors evaluated the efficacy of alternative blood-conservation strategies including preoperative recombinant human erythropoietin (rHuEPO) therapy and acute normovolemic hemodilution (ANH) in radical retropubic prostatectomy patients. METHODS: Seventy-nine patients were prospectively randomized to preoperative autologous donation (3 U autologous blood); rHuEPO plus ANH (preoperative subcutaneous administration of 600 U/kg rHuEPO at 21 and 14 days before surgery and 300 U/kg on day of surgery followed by ANH in the operating room); or ANH (blinded, placebo injections per the rHuEPO regimen listed previously). Transfusion outcomes, perioperative hematocrit levels, postoperative outcomes, and blood-conservation costs were compared among the three groups. RESULTS: Baseline hematocrit levels were similar in all groups (43%+/-2%). On the day of surgery hematocrit decreased to 34% +/-4% in the preoperative autologous donation group (P < 0.001), increased to 47%+/-2% in the rHuEPO plus ANH group (P < 0.001), and remained unchanged at 43%+/-2% in the ANH group. Allogeneic blood exposure was similar in all groups. The rHuEPO plus ANH group had significantly higher hematocrit levels compared with the other groups throughout the hospitalization (P < 0.001). Average transfusion costs were significantly lower for ANH ($194+/-$192) compared with preoperative autologous donation ($690+/-$128; P < 0.001) or rHuEPO plus ANH ($1,393+/-$204, P < 0.001). CONCLUSIONS: All three blood-conservation strategies resulted in similar allogeneic blood exposure rates, but ANH was the least costly technique. Preoperative rHuEPO plus ANH prevented postoperative anemia but resulted in the highest transfusion costs.     

Absence of Beneficial Effect of Acute Normovolemic Hemodilution Combined with Aprotinin on Allogeneic Blood Transfusion Requirements in Cardiac Surgery

Background: The efficacy of acute normovolemic hemodilution (ANH) in decreasing allogeneic blood requirements remains controversial during cardiac surgery.

Methods: In a prospective, randomized study, 80 adult cardiac surgical patients with normal cardiac function and no high risk of ischemic complications were subjected either to ANH, from a mean hematocrit of 43% to 28%, or to a control group. Aprotinin and intraoperative blood cell salvage were used in both groups. Blood (autologous or allogeneic) was transfused when the hematocrit was less than 17% during cardiopulmonary bypass, less than 25% after cardiopulmonary bypass, or whenever clinically indicated.

Results: The amount of whole blood collected during ANH ranged from 10 to 40% of the patients' estimated blood volume. Intraoperative and postoperative blood losses were not different between control and ANH patients (total blood loss, control: 1,411 +/- 570 ml, n = 41; ANH: 1,326 +/- 509 ml, n = 36). Allogeneic blood was given in 29% of control patients (median, 2; range, 1-3 units of packed erythrocytes) and in 33% of ANH patients (median, 2; range, 1-5 units of packed erythrocytes;P = 0.219). Preoperative and postoperative platelet count, prothrombin time, and partial thromboplastin time were similar between groups. Perioperative morbidity and mortality were not different in both groups, and similar hematocrit values were observed at hospital discharge (33.7 +/- 3.9% in the control group and 32.6 +/- 3.7% in the ANH group; nonsignificant)     

Acute normovolemic hemodilution in urologic surgery

PURPOSE: We report the clinical results and efficacy of acute normovolemic hemodilution (ANH) in urologic surgery. PATIENTS AND METHODS: Between October 1996 and February 2001 we performed ANH on 47 patients who were expected to have moderate blood loss during surgical procedures in our hospital. We then evaluated the postoperative hematological features and avoidance of homologous transfusion. RESULTS: Estimated median surgical blood loss was 400 ml (range 10-2,340 ml), and the median amount of whole blood collection was 800 ml (300-1,023 ml). In 14 patients whose blood loss was more than 1,000 ml, the hematocrit (Hct) level in the day after surgery was significantly higher than the Hct level calculated by blood loss. Ninety-eight percent of the series (46/47 cases) and ninety-four percent of patients (15/16 cases) who were underwent radical cystectomy and radical prostatectomy could avoid homologous transfusion. CONCLUSIONS: Our results indicate that ANH is useful during urological surgery, especially in patients with a blood loss of more than 1,000 ml during surgery. ANH is an efficient method for autologous transfusion by means of not only avoidance of homologous transfusion but also by saving red blood cells during surgeries.     

Absence of beneficial effect of acute normovolemic hemodilution combined with aprotinin on allogeneic blood transfusion requirements in cardiac surgery

BACKGROUND: The efficacy of acute normovolemic hemodilution (ANH) in decreasing allogeneic blood requirements remains controversial during cardiac surgery. METHODS: In a prospective, randomized study, 80 adult cardiac surgical patients with normal cardiac function and no high risk of ischemic complications were subjected either to ANH, from a mean hematocrit of 43% to 28%, or to a control group. Aprotinin and intraoperative blood cell salvage were used in both groups. Blood (autologous or allogeneic) was transfused when the hematocrit was less than 17% during cardiopulmonary bypass, less than 25% after cardiopulmonary bypass, or whenever clinically indicated. RESULTS: The amount of whole blood collected during ANH ranged from 10 to 40% of the patients' estimated blood volume. Intraoperative and postoperative blood losses were not different between control and ANH patients (total blood loss, control: 1,411 +/- 570 ml, n = 41; ANH: 1,326 +/- 509 ml, n = 36). Allogeneic blood was given in 29% of control patients (median, 2; range, 1-3 units of packed erythrocytes) and in 33% of ANH patients (median, 2; range, 1-5 units of packed erythrocytes; P = 0.219). Preoperative and postoperative platelet count, prothrombin time, and partial thromboplastin time were similar between groups. Perioperative morbidity and mortality were not different in both groups, and similar hematocrit values were observed at hospital discharge (33.7 +/- 3.9% in the control group and 32.6 +/- 3.7% in the ANH group; nonsignificant) CONCLUSIONS: Hemodilution is not an effective means to lower the risk of allogeneic blood transfusion in elective cardiac surgical patients with normal cardiac function and in the absence of high risk for coronary ischemia, provided standard intraoperative cell saving and high-dose aprotinin are used.     

Induced hypotension with epidural/general anesthesia reduces transfusion in radical prostate surgery

PURPOSE: Radical prostatectomy is associated with substantial blood loss frequently requiring allogeneic blood transfusion. We investigated the efficacy of deliberate hypotension using combined epidural/general anesthesia in reducing allogeneic transfusion requirements in patients undergoing radical prostatectomy. METHODS: In a prospective, randomized, single-blind trial, 102 patients undergoing radical prostatectomy were allocated to either an epidural group (n = 51) or a control group (n = 51). In the epidural group, deliberate hypotension was achieved with a target mean arterial pressure of 55-60 mmHg. The trigger for allogeneic blood transfusion in both groups was a hematocrit value < 0.25. RESULTS: Operative blood loss in the epidural group was significantly less than that in the control group (955 +/- 517 mL vs 1477 +/- 823 mL respectively, P < 0.001). The percentage of patients who reached the threshold trigger for allogenic transfusion was significantly less in the epidural group (8% vs 26%, respectively, P = 0.019) and the number of patients who were actually transfused during hospitalization was also significantly less (P = 0.028). There were no serious adverse events in either group during the study. CONCLUSION: Controlled hypotension using a combined epidural/ general anesthetic technique is associated with significantly less blood loss, and a reduction in the use of allogeneic blood in patients undergoing radical prostatectomy compared to general anesthesia alone.     

Clinical trial of esmolol-induced controlled hypotension with or without acute normovolemic hemodilution in spinal surgery

BACKGROUND: Drug-induced controlled hypotension (CH) combined with acute normovolemic hemodilution (ANH) is being widely used for blood conservation in surgical patients. The purpose of this study was to investigate the efficacy and safety of esmolol-induced CH combined with ANH (hematocrit down to 28%). METHODS: Thirty patients who were scheduled to receive spinal surgery were randomly divided into two groups: an esmolol-induced CH alone group (esmolol group, n=15) and a CH-ANH combined group (E-ANH group, n=15). Controlled hypotension was induced with esmolol 500 micro g/kg, followed by a continuous infusion of 0-300 micro g/kg/min to maintain mean arterial pressure at 55-65 mmHg. RESULTS: The mean infusion rate of esmolol in the esmolol-ANH group was 46+/-6 micro g/kg/min (mean+/-SD), which was significantly lower than the 77+/-9 micro g/kg/min used in the esmolol group (P<0.05). The number of units of homologous blood (packed RBC) transfused perioperatively was 2.2+/-0.6 units in the esmolol-ANH group, which was significantly less than 4.3+/-0.4 units used in the esmolol group (P<0.01). While O2 delivery decreased significantly during CH, O2 consumption remained unchanged in both groups. No complications resulted from CH or ANH in any of the groups. CONCLUSION: Our data suggest that ANH of moderate degree can be combined with esmolol-induced CH to improve blood conservation in surgical patients.     

The usefulness of autologous blood transfusion for urologic surgery]

To avoid potential risks associated with homologous blood transfusion including viral infection and graft versus host disease (GVHD), autologous blood donations have been promoted in urologic surgery. We assessed its necessity in the patients undergoing radical retropubic prostatectomy and total cystectomy. A total of 27 patients ranging from 54 to 78 years old donated 400 to 1,200 ml of blood prior to radical prostatectomy (17 patients) and total cystectomy (10 patients). Recombinant erythropoietin was administered in 26 out of 27 patients. The mean hemoglobin concentration was 14.1 g/dl before donation and 12.8 g/dl before operation. The mean volume of surgical blood loss was 1,659 ml ranging from 529 to 2,990 ml in total cystectomy, and 1,438 ml ranging from 553 to 2,841 ml in radical prostatectomy. Overall, 22 out of 27 patients (82%) did not require an additional homologous blood transfusion. In conclusion, autologous blood donation is a safe and useful method to avoid homologous transfusion in radical prostatectomy and total cystectomy. Eight hundred ml of blood donation is suggested to be appropriate prior to these surgeries.     

Changes in intravascular volume during acute normovolemic hemodilution and intraoperative retransfusion in patients with radical hysterectomy

BACKGROUND: Changes in blood volume during acute normovolemic hemodilution (ANH) and their consequences for the perioperative period have not been investigated sufficiently. METHODS: In 15 patients undergoing radical hysterectomy, preoperative ANH to a hematocrit of 24% was performed using 5% albumin solution. Intraoperatively, saline 0.9% solution was used for volume substitution, and intraoperative retransfusion was started at a hematocrit of 20%. Plasma volume (indocyanine green dilution technique), hematocrit, and plasma protein concentration were measured before and after ANH, before retransfusion, and postoperatively. Red cell volume (labeling erythrocytes with fluorescein) was determined before and after ANH and postoperatively. RESULTS: Mean normal plasma volumes (1,514 +/- 143 ml/m2) and reduced red cell volumes (707 +/- 79 ml/m2) were measured preoperatively. Blood (1,150 +/- 196 ml) was removed and replaced with 1,333 +/- 204 ml of colloid. Blood volume before and after ANH was equal and amounted to 3,740 ml. Intraoperatively, plasma volume did not increase until retransfusion despite infusing 3,389 +/- 1,021 ml of crystalloid (corrected for urine output) to compensate for an estimated surgical blood loss of 727 +/- 726 mi. Postoperatively, after retransfusion of all autologous blood, blood volume was 255 +/- 424 ml higher than preoperatively before ANH. Despite mean calculated blood loss of 1,256 +/- 892 ml, only one patient received allogeneic blood. CONCLUSIONS: During ANH, normovolemia was exactly maintained. After surgical blood loss of 1,256 +/- 892 ml, crystalloid and colloid supplies of 5,752 +/- 1,462 ml and 1,667 +/- 548 ml, respectively, and complete intraoperative retransfusions of autologous blood in every patient, mean blood volume was 250 ml higher than preoperatively before ANH.     

Splanchnic perfusion during controlled hypotension combined with acute hypervolemic hemodilution: a comparison with combination of acute normovolemic hemodilution-gastric intramucosal pH study

STUDY OBJECTIVE: To evaluate the effect of controlled hypotension combined with acute hypervolemic or normovolemic hemodilution on the splanchnic perfusion in the clinical setting. DESIGN: Randomized, prospective study. SETTING: Inpatient surgery at Nagasaki Rosai Hospital. PATIENTS: 28 ASA physical status I and II patients scheduled for total hip arthroplasty.Interventions: Patients were randomly divided into two groups. Group A (n = 14) received controlled hypotension with acute normovolemic hemodilution (ANH). Group B (n = 14) received controlled hypotension with acute hypervolemic hemodilution (HHD). ANH was produced by drawing approximately 1000 mL of blood and replacing it with the same amount of 6% hydroxyethyl starch solution (HES). HHD was produced by preoperative infusion of 1000 mL of 6% HES without removing blood. The final hematocrit values were 24+/-2% (mean +/- SD) in Group A and 25+/-3% in Group B. Controlled hypotension was induced with prostaglandin E1 (PGE1) to maintain mean arterial blood pressure at 55 mmHg for 80 minutes. MEASUREMENTS: Measurements included the gastric pH (pHi), the arterial blood pH (pHa), and plasma lactate. These indices were measured before hemodilution, after hemodilution, 80 minutes after starting hypotension, 60 minutes after recovery from hypotension, and on the first postoperative day. The value of pHi was measured by tonometric method. MAIN RESULTS: The pHa and lactate values showed no change in either group A or group B throughout the time course. Gastric pHi values in group A showed a significant decrease from 7.424+/-0.033 to 7.335+/-0.038 (p<0.05) after hemodilution, whereas it showed no further decrease at 80 minutes after starting hypotension and 60 minutes after recovery from hypotension. The pHi values in group B showed no significant decrease after hemodilution and no further change at 80 minutes after starting hypotension. CONCLUSIONS: HHD does not impair splanchnic perfusion, whereas ANH might cause impairment. Controlled hypotension with prostaglandin E1 would not impair splanchnic perfusion in combination with either HHD or ANH.     

Continuous haemodynamic monitoring using transoesophageal Doppler during acute normovolaemic haemodilution in patients with coronary artery disease

Transoesophageal Doppler monitoring allows non-invasive assessment of stroke volume. We studied haemodynamic changes during acute normovolemic haemodilution (ANH) in anaesthetised patients with coronary artery disease. Twenty patients were randomly assigned to either ANH or a control group. During ANH, a mean (SD) blood volume of 15.3 (3.4) ml.kg(-1) was withdrawn decreasing systemic oxygen delivery from 12.7 (3.3) to 9.3 (1.8) ml.kg(-1).min(-1) (p < 0.001). In the control group, haemodynamic data remained unchanged, whereas in the ANH group, stroke volume and central venous pressure increased significantly (mean = +21 ml [95% CI: 18-25 ml.min(-1)]; mean = +2.5 mmHg [95% CI: 2.2-2.8 mmHg], respectively) and heart rate decreased (mean = -6 beat.min(-1)[95% CI: 6-8 beat.min(-1)], p < 0.05). According to the Frank-Starling relationship, individual changes in stroke volume compared with central venous pressure fitted a quadratic regression model (R2 > 0.91). A reduced viscosity associated with ANH resulted in improved venous return, higher cardiac preload and increased cardiac output. In summary, this study demonstrated that ANH to a haemoglobin value of 8.6 g.dl(-1) was well tolerated in patients with coronary artery disease.