Bilateral nephrectomy impairs cardiovascular function and cerebral perfusion in a rat model of acute hemodilutional anemia

Anemia and renal failure are independent risk factors for perioperative stroke, prompting us to assess the combined impact of acute hemodilutional anemia and bilateral nephrectomy (2Nx) on microvascular brain Po2 (PBro2) in a rat model. Changes in PBro2 (phosphorescence quenching) and cardiac output (CO, echocardiography) were measured in different groups of anesthetized Sprague-Dawley rats (1.5% isoflurane, n = 5-8/group) randomized to Sham 2Nx or 2Nx and subsequently exposed to acute hemodilutional anemia (50% estimated blood volume exchange with 6% hydroxyethyl starch) or time-based controls (no hemodilution). Outcomes were assessed by ANOVA with significance assigned at P < 0.05. At baseline, 2Nx rats demonstrated reduced CO (49.9 ± 9.4 vs. 66.3 ± 19.3 mL/min; P = 0.014) and PBro2 (21.1 ± 2.9 vs. 32.4 ± 3.1 mmHg; P < 0.001) relative to Sham 2Nx rats. Following hemodilution, 2Nx rats demonstrated a further decrease in PBro2 (15.0 ± 6.3 mmHg, P = 0.022). Hemodiluted 2Nx rats did not demonstrate a comparable increase in CO after hemodilution compared with Sham 2Nx (74.8 ± 22.4 vs. 108.9 ± 18.8 mL/min, P = 0.003) that likely contributed to the observed reduction in PBro2. This impaired CO response was associated with reduced fractional shortening (33 ± 9 vs. 51 ± 5%) and increased left ventricular end-systolic volume (156 ± 51 vs. 72 ± 15 µL, P < 0.001) suggestive of systolic dysfunction. By contrast, hemodiluted Sham 2Nx animals demonstrated a robust increase in CO and preserved PBro2. These data support the hypothesis that the kidney plays a central role in maintaining cerebral perfusion and initiating the adaptive increase in CO required to optimize PBro2 during acute anemia.NEW & NOTEWORTHY This study has demonstrated that bilateral nephrectomy acutely impaired cardiac output (CO) and microvascular brain Po2 (PBro2), at baseline. Following acute hemodilution, nephrectomy prevented the adaptive increase in CO associated with acute hemodilution leading to a further reduction in PBro2, accentuating the degree of cerebral tissue hypoxia. These data support a role for the kidney in maintaining PBro2 and initiating the increase in CO that optimized brain perfusion during acute anemia.

Exploration of the Clinical Effect of Different Autotransfusion Methods on Patients With Femoral Shaft Fracture Surgery

OBJECTIVE

To explore the clinical effect of predeposit, salvage, and hemodilution autotransfusion on patients with femoral shaft fracture (FSF) surgery.

METHODS

Selected patients with FSF were randomly divided into three groups: intraoperative blood salvage autotransfusion, preoperative hemodilution autohemotransfusion, and predeposit autotransfusion. Five days after the operation, the body temperature, heart rate, blood platelet (PLT), and hemoglobin (Hb) of patients were determined. The concentrations of EPO and GM-CSF in the three groups were calculated by ELISA. The content of CD14+ monocytes was calculated by FCM assay. The growth time and condition of the patient's callus were determined at the 30th, 45th, and 60th day after operation. Cox regression analysis was used to analyze the correlation between EPO, GM-CSF, CD14+ mononuclear content, callus growth, and autotransfusion methods.

RESULTS

There were no statistically significant differences in body temperature and heart rate between the three groups (p > 0.05). PLT and Hb in the Predeposit group were markedly increased compared with that in the Salvage and Hemodilution groups. The concentrations of EPO and GM-CSF in the Predeposit group were markedly increased compared with that in the Salvage and Hemodilution groups. The content of CD14+ monocytes in the Predeposit group was significantly higher than that in the Salvage and Hemodilution groups. Predeposit autotransfusion promotes callus growth more quickly.

CONCLUSION

Predeposit autotransfusion promoted the recovery of patients with FSF after the operation more quickly than salvage autotransfusion and hemodilution autotransfusion.

Effectiveness, safety and indications of acute normovolemic haemodilution in total knee arthroplasty

Total knee arthroplasty (TKA) is the most cost-effective, and potent method for the treatment of end-stage knee osteoarthritis. Acute normovolemic haemodilution (ANH) can effectively replace the need for allogeneic transfusions due to the high amount of bleeding during TKA. However, more studies are needed to prove the efficacy and safety of ANH and to clarify its indications in the field of knee replacement. Medical records from June 1, 2019 to June 1, 2021 were searched and grouped according to inclusion and exclusion criteria.

PART I

58 patients with ANH during TKA were selected as the ANH group (n = 58), and 58 patients with allogeneic transfusion were chosen as the control group (n = 58).

PART II

Patients with anaemia were divided into the ANH group (n = 18) and the control group (n = 12).

PART I

The postoperative inflammatory index and serum albumin in the ANH group were significantly lower than those in the control group. No significant difference was observed in the theoretical loss of red blood cells, postoperative renal function, liver function, cardiac function and biochemical ion index between the two groups. The effective rate of ANH in the normal haemoglobin group was significantly lower than that in the anaemia group.

PART II

In patients with anaemia, the theoretical loss of red blood cells in patients with ANH was less than that in the control group. The postoperative inflammation, renal function, liver function and cardiac function in the ANH group were better than those in the control group, and no significant difference was noted in biochemical ions and nutritional status indicators. This paper shows that ANH not only can replace allogeneic transfusion in TKA, especially in patients with anaemia, but also has lower inflammatory indicators than allogeneic transfusion. From a security perspective, the body's tolerance to ANH is within the body's compensation range.

Comparing acute normovolumic hemodilution with autologous platelet-rich plasma for blood preservation during aortic surgery : study protocol for a randomized controlled clinical trial

BACKGROUND

Both acute normovolumic hemodilution (ANH) and autologous platelet-rich plasma (aPRP) have been demonstrated blood-protective effects in cardiac aortic surgery; however, the efficacies of the two methods have not been compared. This study aims to compare the effects of aPRP and ANH prior to aortic surgery on postoperative bleed and other outcomes.

METHODS AND ANALYSIS

This is a prospective, single-center, double-blind controlled clinical trial including 160 patients randomized 1:1 to receive aPRP (test group) or autologous whole blood (ANH, control group). The primary objective is to compare the drainage volumes in the two groups at 24, 48, and 72 h postoperatively. Secondary outcomes include input of allogeneic blood and blood products and durations of aortic block, extracorporeal circulation, deep hypothermic arrest of circulation, tracheal extubation, hospital stay, requirement for secondary surgical hemostasis, and application of intra-aortic balloon pump or extracorporeal membrane oxygenation in the two groups. In addition, heart rate, systolic blood pressure, diastolic blood pressure, central venous pressure, and thromboelastography recorded before blood reservation (T1), after blood reservation (T2), before blood transfusion (T3), and after the blood is returned (T4) to the transfusion will be compared between the two groups of patients.

DISCUSSION

This study will demonstrate if the use of aPRP could reduce the risk of bleeding after aortic surgery compared with ANH. The results are expected to have practical clinical applications in terms of more effective blood protection and shorter hospital stay.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ ) with the ID ChiCTR 1900023351.Registered on May 23, 2019.

TRIAL STATUS

Recruiting start date: July 1, 2019; expected recruiting end date: July 1, 2024 Version number and date: Version 2 of 05-04-2019.

Treatments for Acute Nonarteritic Central Retinal Artery Occlusion: Findings From a Cochrane Systematic Review

Many interventions for nonarteritic central retinal artery occlusion (CRAO) are associated with serious complications and little effect on visual outcomes. We report on the findings of a Cochrane systematic review that searched seven databases for peer-reviewed articles reporting on treatments for acute nonarteritic CRAO. We assessed six randomized controlled trials, including interventions such as tissue plasminogen activator (t-PA), isovolumic hemodilution, eyeball massage, intraocular pressure reduction, anticoagulation, vasodilation, oxygen inhalation, laser embolysis, transcorneal electrical stimulation, thrombolysis, pentoxifylline, and enhanced external counterpulsation. However, none of the randomized controlled trials demonstrated significant improvement in visual acuity at 1 month compared to observation, and some patients treated with t-PA experienced serious adverse effects including intracranial hemorrhage. Proposed interventions for acute nonarteritic CRAO may not be better than observation, but the evidence is uncertain. Larger, well-designed studies are necessary to determine the most effective management option for acute nonarteritic CRAO. [Ophthalmic Surg Lasers Imaging Retina 2023;54:650-653.].

Revisiting the benefits of isovolemic hemodilution red cell exchange for sickle cell disease

BACKGROUND

Isovolemic hemodilution red cell exchange (IHD-RCE) is a modified form of the standard red cell exchange (STD-RCE), intended to reduce red cell requirements in patients with sickle cell disease (SCD). This retrospective crossover analysis of nine patients aims to add to the limited existing literature on IHD-RCE and address the equipoise regarding whether the benefits of (a) decreased RBC usage per exchange and (b) increased interprocedure interval (via lower fraction of cells remaining, FCR) can be observed at the same time, in the same patient.

METHODS

At a single center, we identified 37 patients with SCD undergoing chronic RCE between 2014 and 2021. We excluded those patients who did not have at least six consecutive procedures of each type (STD- and IHD-RCE), arriving at nine patients for analysis.

RESULTS

When using greater decreases in hematocrit than previously published, we did not find that IHD-RCE resulted in any clinically apparent adverse events. We did find greater decreases in diastolic blood pressure and increases in heart rate in some patients, as compared to STD-RCE. After correcting for total blood volume, seven of the nine patients had significantly reduced red cell requirements with each IHD-RCE. Because the pattern of achieving a lower FCR than programmed was seen to an equal extent with both IHD-RCE and STD-RCE, none of the nine patients showed any statistical difference in actual FCR between procedure types.

DISCUSSION

Our data do not support the observation of both IHD-RCE benefits, decreased red cell usage per exchange and lower FCR/increased interprocedure interval, simultaneously.

Autologous versus allogeneic blood transfusion: A comparative study of the peri-operative outcomes in a tertiary care hospital in South India amidst the COVID-19 pandemic

Autologous blood transfusion is known to have advantages over allogeneic transfusion. The COVID-19 pandemic intensified the already existing shortage of allogeneic blood supply. We carried out a study during this period with the aim to elicit the effects of autologous blood collection and transfusion, to compare the peri-operative outcomes of autologous and allogeneic transfusion practices and also to assess the influence of the autologous transfusion programme in the Blood Centre inventory. It was prospective observational comparative study among neurosurgical and vascular surgical patients in a tertiary care centre in South India. 141 patients were allocated into Group I (n = 71) who received autologous transfusion and those who received conventional allogeneic transfusion were clustered as Group II (n = 72) for analysis. We employed Acute Normovolemic Hemodilution (ANH), Pre-deposit Autologous Donation (PAD) and Intra-operative Cell Salvage (ICS) as various modalities for autologous blood collection. In our study, 43 (60.6%) from Group I received exclusive autologous blood transfusion, whereas 28 (39.4%) required additional allogeneic transfusion. No significant difference in hemoglobin, hematocrit, platelet count and INR were observed between the groups post transfusion. Significant difference was observed in the thoracoabdominal aortic aneurysm (TAAA) patients with respect to duration of ICU stay (2.7 ± 1.1 days in Group I and 6.2 ± 0.8 days in Group II; p = 0.002) and re-exploration due to bleeding (16.7% in Group I and 40% in Group II; p = 0.048). Autologous blood transfusion is safe and effective. It can be employed as routine practice and also during any acute shortage or pandemic.

Exercise-related hemoconcentration and hemodilution in hydrated and dehydrated athletes: An observational study of the Hungarian canoeists

Hemoconcentration during exercise is a well-known phenomenon, however, the extent to which dehydration is involved is unclear. In our study, the effect of dehydration on exercise-induced hemoconcentration was examined in 12 elite Hungarian kayak-canoe athletes. The changes of blood markers were examined during acute maximal workload in hydrated and dehydrated states. Dehydration was achieved by exercise, during a 120-minute extensive-aerobic preload. Our research is one of the first studies in which the changes in blood components were examined with a higher time resolution and a wider range of the measured parameters. Hydration status had no effect on the dynamics of hemoconcentration during both the hydrated (HS) and dehydrated (DHS) load, although lower maximal power output were measured after the 120-minute preload [HS Hemoglobin(Hgb)Max median 17.4 (q1 17.03; q3 17.9) g/dl vs. DHS HgbMax median 16.9 (q1 16.43; q3 17.6) g/dl (n.s); HS Hematocrit(Hct)Max 53.50 (q1 52.28; q3 54.8) % vs. DHS HctMax 51.90 (q1 50.35; q3 53.93) % (n.s)]. Thirty minutes after the maximal loading, complete hemodilution was confirmed in both exercises. Dehydration had no effect on hemoconcentration or hemodilution in the recovery period [HS HgbR30' 15.7 (q1 15.15; q3 16.05) g/dl (n.s.) vs. DHS HgbR30' 15.75 (q1 15.48; q3 16.13) g/dl (n.s.), HS HctR30' 48.15 (q1 46.5; q3 49.2) % vs. DHS HctR30' 48.25 (q1 47.48; q3 49.45) % (n.s.)], however, plasma osmolality did not follow a corresponding decrease in hemoglobin and hematocrit in the dehydrated group. Based on our data, metabolic products (glucose, lactate, sodium, potassium, chloride, bicarbonate ion, blood urea nitrogen) induced osmolality may not play a major role in the regulation of hemoconcentration and post-exercise hemodilution. From our results, we can conclude that hemoconcentration depends mainly on the intensity of the exercise.

Effects of room temperature and cold storage on the metabolic and haemostatic properties of whole blood for acute normovolaemic haemodilution

Background

Acute normovolaemic haemodilution (ANH), as a blood-conservation technique, avoids the need for allogeneic blood transfusions. The historic practice of cold-storing type-O whole blood (WB) in military fields popularised the transfusion of refrigerated WB to treat acute bleeding. In this study, we compared the effects of room temperature (RT) and refrigeration up to 24 hours on the coagulation properties of WB for ANH.

Materials and methods

Each WB sample, collected from 12 male volunteers, was divided into two parts, one stored at RT and the other refrigerated for 24 hours. Complete blood counts (CBC), blood gas levels, and coagulation profiles were measured, and rotational thromboelastometry (ROTEM) measurements were performed at the initial collection time point (baseline) and at 6, 12, and 24 hours after initial collection.

Results

The preservation of platelet aggregation response induced by arachidonic acid and adenosine diphosphate was better in cold-stored WB compared to that in RT-stored WB. The platelet aggregation response induced by thrombin receptor-activating peptide 6 was significantly decreased in all samples after 24 hours of storage when compared with that at baseline. The lactate levels in WB stored at RT increased significantly after 6 hours of storage compared to that of cold-stored samples. There were no significant differences in CBC, coagulation parameters, and ROTEM variables between the cold-stored and RT-stored WB samples.

Conclusion

WB for ANH stored in the refrigerator showed better metabolic characteristics after 6 hours of storage and better aggregation response after 12 hours of storage than WB stored at RT.

Acute Normovolemic Hemodilution-assisted Terminal Blood Procurement in Swine for Ex Vivo Organ Perfusion

Swine (Sus scrofa domesticus) are commonly used large animal subjects for the study of disease and preclinical therapies. Organ machine perfusion is a therapy that has gained momentum as a research platform for the study of ex vivo organ preservation and therapeutics. However, complex perfusion circuits and research protocols often require large volumes of blood as perfusate. Here, we report a technique for increasing terminal blood yield during swine organ and blood procurement; our method involves acute normovolemic hemodilution and exsanguination via the femoral artery. We collected a total of 47 ± 4 mL/kg of blood and 4.3 ± 0.6 g/kg of hemoglobin, representing 73% ± 6% of the estimated blood volume and 64% ± 8% of the total estimated intravascular hemoglobin (n = 4). Neither pH, lactate, nor pO2 levels changed significantly during blood procurement. Acute normovolemic hemodilution is an effective method for increasing RBC and hemoglobin yield during blood procurement in swine.

Albumin Infusion in Critically Ill COVID-19 Patients: Hemodilution and Anticoagulation

Hypercoagulation is one of the major risk factors for ICU treatment, mechanical ventilation, and death in critically ill patients infected with SARS-CoV-2. At the same time, hypoalbuminemia is one risk factor in such patients, independent of age and comorbidities. Especially in patients with severe SARS-CoV-2-infection, albumin infusion may be essential to improve hemodynamics and to reduce the plasma level of the main marker of thromboembolism, namely, the D-dimer plasma level, as suggested by a recent report. Albumin is responsible for 80% of the oncotic pressure in the vessels. This is necessary to keep enough water within the systemic circulatory system and for the maintenance of sufficient blood pressure, as well as for sufficient blood supply for vital organs like the brain, lungs, heart, and kidney. The liver reacts to a decrease in oncotic pressure with an increase in albumin synthesis. This is normally possible through the use of amino acids from the proteins introduced with the nutrients reaching the portal blood. If these are not sufficiently provided with the diet, amino acids are delivered to the liver from muscular proteins by systemic circulation. The liver is also the source of coagulation proteins, such as fibrinogen, fibronectin, and most of the v WF VIII, which are physiological components of the extracellular matrix of the vessel wall. While albumin is the main negative acute-phase protein, fibrinogen, fibronectin, and v WF VIII are positive acute-phase proteins. Acute illnesses cause the activation of defense mechanisms (acute-phase reaction) that may lead to an increase of fibrinolysis and an increase of plasma level of fibrinogen breakdown products, mainly fibrin and D-dimer. The measurement of the plasma level of the D-dimer has been used as a marker for venous thromboembolism, where a fourfold increase of the D-dimer plasma level was used as a negative prognostic marker in critically ill SARS-CoV-2 hospitalized patients. Increased fibrinolysis can take place in ischemic peripheral sites, where the mentioned coagulation proteins can become part of the provisional clot (e.g., in the lungs). Although critically ill SARS-CoV-2-infected patients are considered septic shock patients, albumin infusions have not been considered for hemodynamic resuscitation and as anticoagulants. The role of coagulation factors as provisional components of the extracellular matrix in case of generalized peripheral ischemia due to hypoalbuminemia and hypovolemia is discussed in this review.

Survival outcomes of acute normovolemic hemodilution in patients undergoing primary debulking surgery for advanced ovarian cancer: A Memorial Sloan Kettering Cancer Center Team Ovary study

OBJECTIVE

To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer.

METHODS

We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012-04/2017). Standard statistical tests were used.

RESULTS

There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618-1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317-1.092); p = 0.093].

CONCLUSIONS

ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits.

Impact of minimal invasive extracorporeal circulation on the need of red blood cell transfusion

OBJECTIVE

Minimal invasive extracorporeal circulation may decrease the need of packed red blood cell transfusions and reduce hemodilution during cardiopulmonary bypass. However, more data are needed on the effects of minimal invasive extracorporeal circulation in more complex cardiac procedures. We compared minimal invasive extracorporeal circulation and conventional extracorporeal circulation methods of cardiopulmonary bypass.

METHODS

A total of 424 patients in the minimal invasive extracorporeal circulation group and 844 patients in the conventional extracorporeal circulation group undergoing coronary artery bypass grafting and more complex cardiac surgery were evaluated. Age, sex, type of surgery, and duration of perfusion were used as matching criteria. Hemoglobin <80 g/L was used as red blood cell transfusion trigger. The primary endpoint was the use of red blood cells during the day of operation and the five postoperative days. Secondary endpoints were hemodilution (hemoglobin drop after the onset of perfusion) and postoperative bleeding from the chest tubes during the first 12 hours after the operation.

RESULTS

Red blood cell transfusions were needed less often in the minimal invasive extracorporeal circulation group compared to the conventional extracorporeal circulation group (26.4% vs. 33.4%, p = 0.011, odds ratio 0.72, 95% confidence interval 0.55-0.93), especially in coronary artery bypass grafting subgroup (21.3% vs. 35.1%, p < 0.001, odds ratio 0.50, 95% confidence interval 0.35-0.73). Hemoglobin drop after onset of perfusion was also lower in the minimal invasive extracorporeal circulation group than in the conventional extracorporeal circulation group (24.2 ± 8.5% vs. 32.6 ± 12.6%, p < 0.001). Postoperative bleeding from the chest tube did not differ between the groups (p = 0.808).

CONCLUSION

Minimal invasive extracorporeal circulation reduced the need of red blood cell transfusions and hemoglobin drop when compared to the conventional extracorporeal circulation group. This may have implications when choosing the perfusion method in cardiac surgery.

Coagulation in hindbrain membrane meningioma patients treated with different injections using acute hypervolemic hemodilution

The aim of this study was to analyze the changes in coagulation in meningioma patients treated with different injections using the method of acute hypervolemic hemodilution (AHH). One hundred fifty hindbrain membrane meningioma patients were randomly divided into 5 groups, 30 per group. The first group were injected 40ml/time with Danhong after anesthesia induction; the second group were injected with 40ml~60ml/time Kangai and combined with interventional chemotherapy and embolization procedure; the third group of AHH were injected with polygeline 15ml/kg; the fourth group were injected with hydroxyethyl starch (130/0.4) sodium chloride in doses of 15ml/kg; the control group underwent basic treatment for lowering blood pressure and lowering blood fat. The changes of coagulation index were recorded before and after surgery and before and after the injection of different medications. Compared to the control group, for the first group of AHH, after being treated for 10 days and 30 days, the concentrations of bone specific alkaline phosphatase (BALP), bone Gla protein (BGP) and pro-collagen carboxy-terminal propeptide (PICP) were higher than that of the control group, the levels of endotoxin (ET) and C-reactive protein (CRP) were decreased compared to the control group (p less than 0.05); for the second group of AHH, after being treated for 10 days, the index of prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (Fg) were not significantly changed, but the related level of vascular endothelial growth factor (VEGF) significantly decreased (p less than 0.05). Comparing the coagulation function index after surgery in the third and fourth groups, there were no significant changes in mean arterial pressure (MAP) level, heart rate (HR) value presented a low decrease, central venous pressure (CVP) level increased and the level of interleukin IL-6 showed a steady state after increasing. Analyzing the levels of interleukin IL-8 and tumor necrosis factor-α (TNF-α) after surgery, it was seen that in the third group they increased and in the fourth group they decreased (p less than 0.05). Danhong injection improved the coagulation function and microcirculation of patients, Kangai injection and interventional chemotherapy and embolization restrained the appearance of tumor angiogenesis, AHH operation with polygeline injection and hydroxyethyl starch (130/0.4) sodium chloride kept blood flow in normal parameters.

Evaluation of acute normovolemic hemodilution in patients undergoing intracranial meningioma resection: A quasi-experimental trial

The aim of this study was to evaluate the safety of acute normovolemic hemodilution (ANH) for patients undergoing intracranial meningioma resection.Eighty patients (aged 48-65 years) with American Society of Anesthesiologists physical status I-II undergoing intracranial meningioma resection were included in this prospective observational study. The patients were randomly divided into group A (ANH group), which underwent a combination of ANH and intraoperative cell salvage (ICS), and group B (control group), which underwent ICS alone. The study parameters were recorded as baseline values before blood drainage (T0), after blood drainage (T1), and before (T2) and after (T3) retransfusion in group A. Whereas in group B, the same parameters were measured 10 minutes after anesthesia induction (T0), before surgery (T1), and before (T2) and after (T3) transfusion of autologous blood.When intraoperative blood loss was <2000 mL, the mean volume of homologous blood transfused in group A patients was 100.8 ± 82.3 mL, compared with the 190.0 ± 91.8 mL in group B. Reduction in homologous blood used in group A was statistically significant (P < .05). In group B, 15.1% patients received homologous blood, whereas only 5.9% patients received homologous blood in group A. The difference in heart rate between both groups at different time points was statistically nonsignificant (P > .05). The mean hemoglobin and hematocrit levels at T1 and T2 in group A were lower than in group B (P < .05). The prothrombin time and activated partial thromboplastin time in both groups were prolonged significantly after T2 (all P < .05), but were all within normal range. There were no significant differences in postoperative hospital stay, mortality, and postoperative infection between the 2 groups.For patients undergoing excision of intracranial meningioma, ANH is an effective procedure to reduce the need for allogeneic transfusions.

Indications for and complications of transfusion and the management of gynecologic malignancies

Anemia, which is highly prevalent in oncology patients, is one of the most established negative prognostic factors for several gynecologic malignancies. Multiple factors can cause or contribute to the development of anemia in patients with gynecologic cancers; these factors include blood loss (during surgery or directly from the tumor), renal impairment (caused by platinum-based chemotherapy), and marrow dysfunction (from metastases, chemotherapy, and/or radiation therapy). Several peri- and intra-operative strategies can be used to optimize patient management and minimize blood loss related to surgery. Blood transfusions are routinely employed as corrective measures against anemia; however, blood transfusions are one of the most overused healthcare interventions. There are safe and effective evidence-based blood transfusion strategies used in other patient populations that warrant further investigation in the surgical oncology setting. Blood is a valuable healthcare resource, and clinicians can learn to use it more judiciously through knowledge of the potential risks and complications of blood interventions, as well as the ability to properly identify the patients most likely to benefit from such interventions.

Haemodilution in acute ischaemic stroke comparison of two haemodilution regimen

In a prospective study we randomly allocated 50 patients with acute ischaemic stroke in the area of the middle cerebral artery within 12 hours after onset to two moderate hypervolemic haemodilution regimen consisting of 500 ml of 10% hydroxyethyl starch per day for 10 days. In the high haematocrit group the target haematocrit of 41-42% was achieved by 0-3 phlebotomies and additional replacement of that volume with the colloid in 3 days. In the low haematocrit group with 1-4 phlebotomies a target haematocrit of 37-38% was reached in 4 days. The groups did not differ regarding age, risk factors, haematocrit and neurological score. The improvement of the disturbed blood rheology was more pronounced in the low haematocrit group. One death occurred in each group. The neurological score showed a significantly greater increase in the low haematocrit group with +59% at day 5 and +125% at day 11; the data for the high haematocrit group were +34% and +89% respectively. We calculated a correlation (r = 0.36, p less than 0.02) between the rise in neurological score and the reduction of haematocrit. Our data suggest but not do prove that an early start on moderate hypervolemic haemodilution is beneficial in patients with acute ischaemic stroke and disturbed blood rheology.

The impact of hematocrit on oxygenation-sensitive cardiovascular magnetic resonance

BACKGROUND

Oxygenation-sensitive (OS) Cardiovascular Magnetic Resonance (CMR) is a promising utility in the diagnosis of heart disease. Contrast in OS-CMR images is generated through deoxyhemoglobin in the tissue, which is negatively correlated with the signal intensity (SI). Thus, changing hematocrit levels may be a confounder in the interpretation of OS-CMR results. We hypothesized that hemodilution confounds the observed signal intensity in OS-CMR images.

METHODS

Venous and arterial blood from five pigs was diluted with lactated Ringer solution in 10 % increments to 50 %. The changes in signal intensity (SI) were compared to changes in blood gases and hemoglobin concentration. We performed an OS-CMR scan in 21 healthy volunteers using vasoactive breathing stimuli at baseline, which was then repeated after rapid infusion of 1 L of lactated Ringer's solution within 5-8 min. Changes of SI were measured and compared between the hydration states.

RESULTS

The % change in SI from baseline for arterial (r = -0.67, p < 0.0001) and venous blood (r = -0.55, p = 0.002) were negatively correlated with the changes in hemoglobin (Hb). SI changes in venous blood were also associated with SO2 (r = 0.68, p < 0.0001) and deoxyHb concentration (-0.65, p < 0.0001). In healthy volunteers, rapid infusion resulted in a significant drop in the hemoglobin concentration (142.5 ± 15.2 g/L vs. 128.8 ± 15.2 g/L; p < 0.0001). Baseline myocardial SI increased by 3.0 ± 5.7 % (p = 0.026) following rapid infusion, and in males there was a strong association between the change in hemoglobin concentration and % changes in SI (r = 0.82, p = 0.002). After hyperhydration, the SI response after hyperventilation was attenuated (HV, p = 0.037), as was the maximum SI increase during apnea (p = 0.012). The extent of SI attenuation was correlated with the reduction in hemoglobin concentration at the end of apnea (r = 0.55, p = 0.012) for all subjects and at maximal SI (r = 0.63, p = 0.037) and the end of breath-hold (r = 0.68, p = 0.016) for males only.

CONCLUSION

In dynamic studies using oxygenation-sensitive CMR, the hematocrit level affects baseline signal intensity and the observed signal intensity response. Thus, the hydration status of the patient may be a confounder for OS-CMR image analysis.

RECURARIZATION AFTER ACUTE INTRAOPERATIVE NORMOVOLEMIC HEMODILUTION AND USE OF SUGAMMADEX

Acute normovolemic hemodilution (ANH) is a blood conservation procedure that can be used in cases of refusal of blood transfusion for religious reasons. Herein, we describe a case of recurarization after reinfusion of collected blood. A combination of rocuronium/sugammadex has the potential to increase the safety of patients if ANH is done after induction. Prospective controlled studies evaluating this unique indication for sugammadex use are thus warranted.

[PERIOPERATIVE BLOOD MANAGEMENT STRATEGIES FOR JOINT ARTHROPLASTY]

OBJECTIVE

To summarize the perioperative blood management strategies for joint arthroplasty.

METHODS

The literature concerning preoperative, intraoperative, and postoperative blood management was reviewed and summarized.

RESULTS

At present, a variety of blood management and conservation strategies are available. Preoperative strategies include iron supplementation, erythropoietin (EPO), and preoperative autologous donation (PAD). Intraoperative options include acute normovolemic hemodilution (ANH), antifibrinolytics, and the use of a tourniquet. Postoperative strategies include the use of reinfusion systems and guided transfusion protocols. Preoperatively, administration of either simple EPO or a combination of EPO and PAD can be efficacious in anemic patients. Intraoperatively, tourniquet use and tranexamic acid can effectively control bleeding. Postoperatively, appropriate transfusion indications can avoid unnecessary blood transfusions.

CONCLUSION

Perioperative blood management strategies for joint arthroplasty should be integrated for the individual patient using a variety of ways to reduce perioperative blood loss and blood transfusion, and promote the rehabilitation of patients.

Effect of Acute Normovolemic Hemodilution Combined with Controlled Low Central Venous Pressure on Blood Coagulation Function and Blood Loss in Patients Undergoing Resection of Liver Cancer Operation

BACKGROUND/AIMS

This paper aims to investigate the effect of acute normovolemic hemodilution (ANH) used with controlled low central venous pressure (LCVP) technology on perioperative bleeding and coagulation in hepatocellular carcinoma operation patients.

METHODOLOGY

A total of 60 cases undergoing hepatic resection operation were randomly divided into the control group, LCVP group (Group II), and ANH + LCVP group (Group III). The changes of hemodynamic indexes at different time points in each group were observed and recorded, along with the volume of allogenous blood transfusion and the number of patients undergoing allogenous blood transfusion.

RESULTS

Compared with Group I (control), there was evident reduction of the bleeding volume, allogenic blood transfusion volume, and number of patients undergoing allogenic blood transfusion in Groups II and III.

CONCLUSION

The application of ANH combined with LCVP in hepatic resection can evidently reduce intraoperative hemorrhages and homologous blood transfusions; moreover, it has no significant adverse effect on the coagulation function.

[Predictors of renal dysfunction and its correction in women with preeclampsia and alimentary obesity]

Alimentary obesity (AO) is considered as an independent risk factor for preeclampsia (PE). Diagnosis of renal dysfunction in the development of PE is difficult.

OBJECTIVE

Early detection of renal dysfunction in women with PE and AO and substantiation of principles of pathogenetic therapy.

DESIGN

A randomized controlled study of 63 pregnant women.

PATIENTS AND METHODS

Average age--27.4 ± 1.6 years. First group--31 women with PE of moderate severity and AO who received usual intensive therapy (IT). Second group--32 women with PE of moderate severity and AO who received differentiated therapy for improvement of renal function. During the IT we accounted solute free water clearance (FWC) and colloid oncotic pressure (COP). If FWC was less than 0.45 ml /min, and the COP--less than 18 mm Hg, we started 6% HES administering 130/4 (6.5 ml/kg/day with a rate of 350 ml/h). After that we administered magnesium sulfate (0.75 ml/kg/day, with a rate of 2.8 ml/hr). We evaluated osmotic renal function and tubular function according to β2- microglobulin concentration of urine, glomerular filtration rate (GFR ) according to Rehberg Tareev method and Cockroft-Gault formula and the Modification of Diet in Renal Disease Study (6-v MDRD).

RESULTS

Baseline renal dysfunction was observed in 87.3% of women with PE and AO. Determination of GFR is effective according to Rehberg-Tareev. Cockroft-Gault formula and 6-v MDRD unsuitable in case of PE and AO. Common IT corrected renal dysfunction in 54.8% of women and differentiated IT in 81.2% of women with PE and AO. Intensive therapy did not lead to the recovery of kidney function in 45.2% in the first group and 18.8% in the second group.

Haemodilution for acute ischaemic stroke

BACKGROUND

Ischaemic stroke interrupts the flow of blood to part of the brain. Haemodilution is thought to improve the flow of blood to the affected areas of the brain and thus reduce infarct size.

OBJECTIVES

To assess the effects of haemodilution in acute ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2014), the Cochrane Central Register of Controlled Trials (Issue 1, 2014), MEDLINE (January 2008 to October 2013) and EMBASE (January 2008 to October 2013). We also searched trials registers, scanned reference lists and contacted authors. For the previous version of the review, the authors contacted manufacturers and investigators in the field.

SELECTION CRITERIA

Randomised trials of haemodilution treatment in people with acute ischaemic stroke. We included only trials in which treatment was started within 72 hours of stroke onset.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and one review author extracted the data.

MAIN RESULTS

We included 21 trials involving 4174 participants. Nine trials used a combination of venesection and plasma volume expander. Twelve trials used plasma volume expander alone. The plasma volume expander was plasma alone in one trial, dextran 40 in 12 trials, hydroxyethyl starch (HES) in five trials and albumin in three trials. Two trials tested haemodilution in combination with another therapy. Evaluation was blinded in 14 trials. Five trials probably included some participants with intracerebral haemorrhage. Haemodilution did not significantly reduce deaths within the first four weeks (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.90 to 1.34). Similarly, haemodilution did not influence deaths within three to six months (RR 1.05; 95% CI 0.93 to 1.20), or death and dependency or institutionalisation (RR 0.96; 95% CI 0.85 to 1.07). The results were similar in confounded and unconfounded trials, and in trials of isovolaemic and hypervolaemic haemodilution. No statistically significant benefits were documented for any particular type of haemodiluting agents, but the statistical power to detect effects of HES was weak. Six trials reported venous thromboembolic events. There was a tendency towards reduction in deep venous thrombosis or pulmonary embolism or both at three to six months' follow-up (RR 0.68; 95% CI 0.37 to 1.24). There was no statistically significant increased risk of serious cardiac events among haemodiluted participants.

AUTHORS' CONCLUSIONS

The overall results of this review showed no clear evidence of benefit of haemodilution therapy for acute ischaemic stroke.These results are compatible with no persuasive beneficial evidence of haemodilution therapy for acute ischaemic stroke. This therapy has not been proven to improve survival or functional outcome.

The accuracy of non-invasively continuous total hemoglobin measurement by pulse CO-Oximetry undergoing acute normovolemic hemodilution and reinfusion of autologous blood

BACKGROUND

Non-invasively continuous total hemoglobin (SpHb) measurement has not been assessed adequately in acute bleeding and rapid blood transfusion during surgery. Thus, we have assessed the efficacy of SpHb during both acute normovolemic hemodilution (ANH) and autologous blood transfusion (ABT).

METHODS

Twenty-four patients undergoing urological and gynecological surgery were enrolled. ANH was induced by withdrawing blood of 800 g with simultaneous fluid administration. When surgical hemostasis was completed, collected blood was reinfused. Measurement of SpHb, perfusion index (PI) and real total Hb (tHb) were done before and after each 400 ml blood removal (-0, -400, -800 ml) and reinfusion (+0, +400, +800 ml).

RESULTS

A Bland-Altman analysis for repeated measurements showed a bias (precision) g/dl of 1.12 (1.25), 1.43 (1.24) and 1.10 (1.23) for all data, during ANH and during ABT, respectively. Additionally, a bias (precision) increased with a reduction in tHb (g/dl): ≥10.0; 0.74 (1.30), 8.0-10.0; 1.15 (1.12) and <8.0; 1.60 (1.28). Although the difference between SpHb and tHb was almost zero before anesthesia induction, it became significant just before ANH and did not change further by ANH and ABT. Significant correlations between SpHb and tHb for all data (r = 0.75, n = 228, p < 0.001) were observed. PI slightly correlated with the difference between SpHb and tHb (r = 0.38, n = 216, p < 0.001). Furthermore, before and after induction of anesthesia, PI also correlated with the difference between SpHb and tHb (r = 0.42, n = 23, p = 0.048 and r = 0.51, n = 22, p = 0.016, respectively).

CONCLUSIONS

The present data suggest that SpHb may overestimate tHb during ANH and ABT. In addition, PI and tHb levels had an impact on the accuracy of SpHb measurements.

Low central venous pressure versus acute normovolemic hemodilution versus conventional fluid management for reducing blood loss in radical retropubic prostatectomy: a randomized controlled trial

OBJECTIVE

To compare acute normovolemic hemodilution versus low central venous pressure strategy versus conventional fluid management in reducing intraoperative estimated blood loss, hematocrit drop and need for blood transfusion in patients undergoing radical retropubic prostatectomy under general anesthesia.

RESEARCH DESIGN AND METHODS

Patients undergoing radical retropubic prostatectomy under general anesthesia were randomized to conventional fluid management, acute normovolemic hemodilution or low central venous pressure (≤5 mmHg). Treatment effects on estimated blood loss and hematocrit change were tested in multivariable regression models accounting for surgeon, prostate size, and all two-way interactions.

RESULTS

Ninety-two patients completed the study. Estimated blood loss (mean ± SD) was significantly lower with low central venous pressure (706 ± 362 ml) compared to acute normovolemic hemodilution (1103 ± 635 ml) and conventional (1051 ± 714 ml) groups (p = 0.0134). There was no difference between the groups in need for blood transfusion, or hematocrit drop from preoperative values. The multivariate model predicting estimated blood loss showed a significant effect of treatment (p = 0.0028) and prostate size (p = 0.0323), accounting for surgeon (p = 0.0013). In the model predicting hematocrit change, accounting for surgeon difference (p = 0.0037), the treatment effect depended on prostate size (p = 0.0007) with the slope of low central venous pressure differing from the other two groups. Hematocrit was predicted to drop more with increased prostate size in acute normovolemic hemodilution and conventional groups but not with low central venous pressure.

KEY LIMITATIONS

Limitations include the inability to blind providers to group assignment, possible variability between providers in estimation of blood loss, and the relatively small sample size that was not powered to detect differences between the groups in need for blood transfusion.

CONCLUSIONS

Maintaining low central venous pressure reduced estimated blood loss compared to conventional fluid management and acute normovolemic hemodilution in patients undergoing radical retropubic prostatectomy but there was no difference in allogeneic blood transfusion between the groups.

Hemodynamics and tissue oxygenation after hemodilution with ultrahigh molecular weight polymerized albumin

BACKGROUND

Compared to blood transfusion, plasma expanders (PEs) are more cost effective, have a longer shelf-life, and elicit a milder immune response. High molecular weight (MW) dextrans preserve microvascular function during extreme hemodilution. Dextrans, however, evokes negative hemostatic effects, including red blood cell (RBC) aggregation and reduce platelet adhesion, that limit their clinical use. Therefore, polymerization of human serum albumin (HSA) presents a simple strategy to increase HSA's molecular size.

METHODS

This study was designed to test the hypothesis that polymerized HSA (PolyHSA) biophysical properties improves systemic and microvascular hemodynamics when used as a PE under anemic conditions. The study was implemented using the hamster window chamber model. Animals were first hemodiluted to 18% hematocrit (Hct) using 6% dextran 70 kDa and then to 11% Hct using either 10% PolyHSA, 10% unpolymerized HSA, or 6% dextran 70 kDa. Systemic and microvascular hemodynamics, including cardiac output (CO), mean arterial blood pressure (MAP), functional capillary density (FCD), microvascular perfusion, and oxygen tension were measured.

RESULTS

Posthemodilution, PolyHSA improved MAP, CO, and oxygen delivery compared to HSA and dextran. Additionally, PolyHSA improved microvascular function in terms of blood flow and FCD. Although oxygen carrying capacity is limited at 11% Hct, tissue pO2 and oxygen delivery were higher for PolyHSA compared to HSA and dextran.

CONCLUSION

PolyHSA during extreme anemia supported systemic and microvascular hemodynamics by increasing plasma viscosity without increasing vascular resistance. These findings can aid to design of studies to understand the role of the PE biophysical properties in clinical scenarios.

[Case of Rh (-) patient's right lobectomy of the liver with massive hemorrhage evading allogeneic blood transfusion by hemodilutional autologous blood transfusion]

A 44-year-old man (ASA-PS 1) underwent right lobectomy of the liver under total intravenous anesthesia with propofol, remifentanil, ketamine and rocuronium. In order to evade allogeneic blood transfusion, 1,200 g of the patient's blood was taken and hemodilution was induced for autologous blood transfusion (HAT) after the induction of anesthesia. As intraoperative blood loss amounted to about 4,000 g, Hb level decreased from 13.6 to 6.2 g x dl(-1). However, as intraoperative hemodynamics was relatively stable with crystalloidal and colloidal transfusion with no ischemic change on ECG and no metabolic acidosis, autologous blood transfusion was withheld. After returning the autologous blood, Hb increased to 9.8 g x dl(-1). Any postoperative complications related to the low Hb level were not recognized. HAT is a useful method to evade or at least decrease the amount of allogeneic blood transfusion by anesthesiologists.

Influence of acute normovolemic hemodilution on the pharmacokinetics of Cisatracurium Besylate

BACKGROUND

Acute normovolemic hemodilution (ANH) is an efficacious blood conservation strategy for avoiding or reducing allogeneic blood transfusion. In a previous publication, on a different cohort of patients, we demonstrated that cisatracurium's potency and duration of action were not influenced by ANH, but we could not establish which role, if any, pharmacokinetics played.

METHODS

Forty patients were randomly allocated to the ANH or control groups. Patients received cisatracurium single 100 µg kg-1 bolus dose, serial arterial blood samples were collected and assayed for pharmacokinetic analysis.

RESULTS

Central and steady state apparent volumes of distribution (V1, Vdss) and slope factor (γ) were larger, effect-compartment concentration at 50% neuromuscular block was lower in the ANH (90.8±41.6 mL kg-1, 159.1±39.2 mL kg-1, 6.0±0.9 and 136.4±29.1 ng·mL-1) compared with the control group (65.5±26.1 mL kg-1, 134.8±31.8 mL kg-1, 5.5±0.8 and 158.5±26.0 ng·mL-1) respectively. Elimination half-life (t1/2 β) and mean residence time (MRT) were longer in the ANH (37.2±20.9, 23.5±13.2 min) than the control group (26.8±9.8, 16.9±6.2 min), albeit not statistically significant (P=0.051, P=0.051). There were no significant differences in distribution half-life (t1/2 α), effect-compartment equilibration rate-constant (keo), central and total clearances (Clc, Cl) between the ANH (2.4±1.2 min, 0.070±0.013 min-1, 6.1±1.9 mL kg-1 min-1 and 7.7±2.3 mL kg-1 min-1) and control group (1.9±1.2 min, 0.063±0.008 min-1, 7.0±1.8 mL kg-1 min-1 and 8.5±2.1 mL kg-1 min-1) respectively.

CONCLUSION

ANH altered some pharmacokinetic parameters such as significantly larger volumes of distribution. Other parameters such as elimination half-life were considerably longer albeit not statistically significant.

Acid-base and electrolyte status during normovolemic hemodilution with succinylated gelatin or HES-containing volume replacement solutions in rats

Background

In the past, several studies have compared different colloidal replacement solutions, whereby the focus was usually on the respective colloid. We therefore systematically studied the influence of the carrier solution’s composition of five approved colloidal volume replacement solutions (Gelafundin, Gelafusal, Geloplasma, Voluven and Volulyte) on acid-base as well as electrolyte status during and following acute severe normovolemic hemodilution. The solutions differed in the colloid used (succinylated gelatin vs. HES) and in the presence and concentration of metabolizable anions as well as in their electrolyte composition.

Methods

Anesthetized Wistar rats were subjected to a stepwise normovolemic hemodilution with one of the solutions until a final hematocrit of 10%. Subsequent to dilution (162 min), animals were observed for an additional period (150 min). During dilution and observation time blood gas analyses were performed eight times in total. Additionally, in the Voluven and Volulyte groups as well as in 6 Gelafundin animals, electrolyte concentrations, glucose, pH and succinylated gelatin were measured in urine and histopathological evaluation of the kidney was performed.

Results

All animals survived without any indications of injury. Although the employed solutions differed in their respective composition, comparable results in all plasma acid-base and electrolyte parameters studied were obtained. Plasma pH increased from approximately 7.28 to 7.39, the plasma K⁺ concentration decreased from circa 5.20 mM to 4.80-3.90 mM and the plasma Cl⁻ concentration rose from approximately 105 mM to 111–120 mM. Urinary analysis revealed increased excretion of K⁺, H⁺ and Cl⁻.

Conclusions

The present data suggest that the carrier solution’s composition with regard to metabolizable anions as well as K⁺, Ca²⁺ only has a minor impact on acid-base and electrolyte status after application of succinylated gelatin or HES-containing colloidal volume replacement solutions.

The pre-treatment effect on brain injury during restoration of normal perfusion pressure with hemodilution in a new rat model of chronic cerebral hypoperfusion

OBJECTIVES

To investigate the effect of hemodilution with high-concentration human serum albumin (HSA) on brain injury in a rat model of chronic cerebral hypoperfusion associated with arteriovenous malformations.

METHODS

The animal model was established by creating a fistula through an end-to-side anastomosis between the right distal external jugular vein and the ipsilateral common carotid artery, followed by ligation of the left vein draining the transverse sinus and bilateral external carotid arteries. The agent (20% HSA) or control solution (0.9% sodium chloride) was administered intravenously at a dosage of 1% body weight 24 hours before ligation of the fistula. Blood-brain barrier (BBB) disruption was judged by extravasation of Evans blue (EB) dye. EB, water content and the changes of myeloperoxidase (MPO) activity and superoxide dismutase (SOD) activity in rat brains 24 hours after ligation of the fistula were determined.

RESULTS

EB and water content in rat brains of the pre-treated group were significantly decreased compared with the control group accompanied by reduction of MPO activity and enhancement of SOD activity.

DISCUSSION

Hemodilution with high-concentration HSA has a certain pre-treatment effect on brain injury after ligation of the fistula in rat model of chronic cerebral hypoperfusion, which may be resulted from improved microcirculation, decrease in inflammatory cell infiltration and inactivation of oxygen free radicals.

Total blood volume of Asian patients undergoing cardiac surgery is far from that predicted by conventional methods

AIM

Current cardiopulmonary bypass (CPB) procedures use non-hematic fluids to prime bypass circuits, often resulting in marked hemodilution. Patients' total blood volume (TBV) is estimated prior to hemodilution. We aimed to evaluate differences between calculation of TBV by Nadler's formula, a classic reference book method, and an established formula calculated by the authors.

METHODS

A total of 285 patients of Asian origin received primary cardiac surgery between September 2010 and October 2011 in our institution. Patients' total blood volume was estimated by: 1) standard Nadler formula: TBV (men) =0.417H3+0.045TBM-0.030L TBM (total body mass, Kg); TBV (women) =0.414H3+0.0328 TBM-0.030L; 2) classic reference book method: patient's weight in kilograms times 7% (women) or 7.5% (men); and 3) our practical calculation: TBV=HCT2*(CPB prime volume + intravenous fluids before CPB - urine volume before CPB)/(HCT1- HCT2).

RESULTS

Bland-Altman plotting revealed no mean differences between Nadler formula and reference book TBV measurements (Figure 1A). Differences in means (95% limit of agreement) for reference book/Nadler formulas was 0.52 (-0.21, 1.24, N.=285). Comparing authors' results with those of reference book/Nadler, TBV yielded divergent results. TBV correlated positively to patient's height (P=0.001) and body surface area (P<0.01), and correlated positively to height after controlling for age and gender (β=87.3, SE=42.9, P=0.043).

CONCLUSION

Total blood volume of Asian patients calculated by the authors differs markedly from that estimated by Nadler and classic reference book formulas, which suggests that more accurate calculation of TBV is needed for Asian cardiac patients requiring CPB, especially patients with valvular disease.

The association between fluid balance and outcomes after subarachnoid hemorrhage

BACKGROUND

We sought to determine the association between early fluid balance and neurological/vital outcome of patients with subarachnoid hemorrhage.

METHODS

Hospital admission, imaging, ICU and outcome data were retrospectively collected from the medical records of adult patients with aneurysmal SAH admitted to a level-1 trauma and stroke referral center during a 5-year period. Two groups were identified based on cumulative fluid balance by ICU day 3: (i) patients with a positive fluid balance (n = 221) and (ii) patients with even or negative fluid balance (n = 135). Multivariable logistic regression was used to adjust for age, Hunt-Hess and Fisher scores, mechanical ventilation and troponin elevation (>0.40 ng/ml) at ICU admission. The primary outcome was a composite of hospital mortality or new stroke.

RESULTS

Patients with positive fluid balance had worse admission GCS and Hunt-Hess score, and by ICU day 3 had cumulatively received more IV fluids, but had less urine output when compared with the negative fluid balance group. There was no difference in the odds of hospital death or new stroke (adjusted OR: 1.47, 95%CI: 0.85, 2.54) between patients with positive and negative fluid balance. However, positive fluid balance was associated with increased odds of TCD vasospasm (adjusted OR 2.25, 95%CI: 1.37, 3.71) and prolonged hospital length of stay.

CONCLUSIONS

Although handling of IV fluid administration was not an independent predictor of mortality or new stroke, patients with early positive fluid balance had worse clinical presentation and had greater resource use during the hospital course.

Decreasing the need for transfusion: infant cardiac surgery using hemodilution and recombinant factor VIIa

Many strategies, including intraoperative acute normovolemic hemodilution (ANH) and pharmacologic agents, exist to minimize the use of allogeneic blood products in pediatric congenital heart surgery. Recombinant activated factor VIIa (rFVIIa) is a hemostatic agent approved for the treatment of bleeding episodes and prevention of bleeding in surgical interventions in patients with hemophilia A or B with inhibitors, acquired hemophilia, or congenital factor VII deficiency. Off-label use in nonhemophilic patients for uncontrolled hemorrhage is increasing although still under investigation. We present our experience with ANH and rFVIIa in nine patients. All were <16 months of age and underwent complex cardiac surgery with the end point of achieving hemostasis while decreasing or eliminating the need for allogeneic blood products. Clinically, we have observed rapid hemostasis in patients who underwent ANH and then had autologous blood reinfused after cardiopulmonary bypass, along with rFVIIa, without any time delay. The patients required no allogeneic blood products and therefore results suggested the potential utility of this practice. The study group consisted of nine patients <16 months of age who received rFVIIa in the operating room after open-heart surgery. Amount of autologous blood removed preoperatively, blood product use, time from protamine to rFVIIa administration, platelet count, INR, and fibrinogen level were retrospectively obtained. Of the nine patients, the three who underwent the most aggressive hemodilution received rFVIIa most rapidly and required no allogeneic blood products to achieve hemostasis although they had an average lower fibrinogen level on admission to the cardiothoracic intensive care unit. These preliminary data suggest that hemodilution before surgical stimulation and the rapid administration of rFVIIa, along with the reintroduction of autologous blood, may decrease or potentially eliminate the need for allogeneic blood products. Prospective trials are warranted to further explore this technique.

Cerebral oximetry monitoring during preoperative phlebotomy to limit allogeneic blood use in patients undergoing cardiac surgery

Preoperative phlebotomy can minimize the need for allogenic blood products. Frequently, removed blood is replaced with intravenous fluids to maintain euvolemia (acute normovolemic hemodilution [ANH]). During cardiopulmonary bypass (CPB), ANH may present problems when the circuit prime causes further hemodilution and unacceptably low hemoglobin. This investigation aimed to demonstrate that minimum volume replacement after preoperative phlebotomy can be used safely when guided by cerebral oxygenation (rSO(2)) measured by near-infrared spectroscopy (NIRS). This prospective study included patients undergoing surgery for congenital heart disease. After preoperative phlebotomy, fluid replacement was guided by mean arterial pressure (MAP), heart rate, and rSO(2), which were measured at baseline, immediately after phlebotomy, and 15 and 30 min after phlebotomy. This study enrolled 38 patients ages 3 months to 50 years. Preoperative phlebotomy removed 9.3 ± 2.9 mL/kg of blood, and 5.6 ± 5.1 mL/kg of crystalloid was administered intraoperatively. Within 30 min after phlebotomy, 23 patients had a MAP decrease of 20 % or more from baseline. This fall in MAP coincided with a decrease in rSO(2) of 20 or more at 2 of 114 measured points. Initially, rSO(2) decreased from 74 ± 9 to 68 ± 10 but thereafter remained constant. On five occasions, rSO(2) decreased 20 or more from baseline, but no patient's NIRS value was less than 45. A decrease in rSO(2) occurred more commonly in younger patients and those who had a larger volume of blood removed. Preoperative phlebotomy without significant volume replacement can be performed safely before CPB. Volume replacement may be more appropriately guided by rSO(2) than by hemodynamic variables.

Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection

BACKGROUND

Blood loss during liver resection is considered one of the most important factors affecting the peri-operative outcomes of patients undergoing liver resection.

OBJECTIVES

To determine the benefits and harms of cardiopulmonary interventions to decrease blood loss and to decrease allogeneic blood transfusion requirements in patients undergoing liver resections.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2012 to identify randomised trials.

SELECTION CRITERIA

We included all randomised clinical trials comparing various cardiopulmonary interventions aimed at decreasing blood loss and allogeneic blood transfusion requirements in patients undergoing liver resection. Trials were included irrespective of whether they included major or minor liver resections of normal or cirrhotic livers, vascular occlusion was used or not, and irrespective of the reason for liver resection.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case analysis. For dichotomous outcomes with only one trial included under the outcome, we performed the Fisher's exact test.

MAIN RESULTS

Ten trials involving 617 patients satisfied the inclusion criteria. The interventions included low central venous pressure (CVP), autologous blood donation, haemodilution, haemodilution with controlled hypotension, and hypoventilation. Only one or two trials were included under most comparisons. All trials had a high risk of bias. There was no significant difference in the peri-operative mortality in any of the comparisons: low CVP versus no intervention (3 trials, 0/88 (0%) patients in the low CVP group versus 1/89 (1.1%) patients in the no intervention group); autologous blood donation versus no intervention (1 trial, 0/40 (0%) versus 0/39 (0%)); haemodilution versus no intervention (2 trials, 1/73 (1.4%) versus 3/77 (3.9%) in one of these trials); haemodilution with controlled hypotension versus no intervention (1 trial, 0/10 (0%) versus 0/10 (0%)); haemodilution with bovine haemoglobin (HBOC-201) versus haemodilution with hydroxy ethyl starch (HES) (1 trial, 1/6 (16.7%) versus 0/6 (0%)); hypoventilation versus no intervention (1 trial, 0/40 (0%) versus 0/39 (0%)). None of the trials reported long-term survival or quality of life. The risk ratio of requiring allogeneic blood transfusion was significantly lower in the haemodilution versus no intervention groups (3 trials, 16/115 (weighted proportion = 14.2%) versus 41/118 (34.7%), RR 0.41 (95% CI 0.25 to 0.66), P = 0.0003); and for haemodilution with controlled hypotension versus no intervention (1 trial, 0/10 (0%) versus 10/10 (100%), P < 0.0001). There were no significant differences in the allogeneic transfusion requirements in the other comparisons which reported this outcome, such as low CVP versus no intervention, autologous blood donation versus control, and hypoventilation versus no intervention.

AUTHORS' CONCLUSIONS

None of the interventions seemed to decrease peri-operative morbidity or offer any long-term survival benefit. Haemodilution shows promise in the reduction of blood transfusion requirements in liver resection surgery. However, there is a high risk of type I (erroneously concluding that an intervention is beneficial when it is actually not beneficial) and type II errors (erroneously concluding that an intervention is not beneficial when it is actually beneficial) because of the few trials included, the small sample size in each trial, and the high risk of bias in the trials. Further randomised clinical trials with low risk of bias and random errors that assess clinically important outcomes such as peri-operative mortality are necessary to assess any cardiopulmonary interventions aimed at decreasing blood loss and blood transfusion requirements in patients undergoing liver resections. Trials need to be designed to assess the effect of a combination of different interventions in liver resections.

Use of pulse pressure variation to estimate changes in preload during experimental acute normovolemic hemodilution

BACKGROUND

Acute normovolemic hemodilution (ANH) is an alternative to blood transfusion in surgeries involving blood loss. This experimental study was designed to evaluate whether pulse pressure variation (PPV) would be an adequate tool for monitoring changes in preload during ANH, as assessed by transesophageal echocardiography.

METHODS

Twenty-one anesthetized and mechanically ventilated pigs were randomized into three groups: CTL (control), HES (hemodilution with 6% hydroxyethyl starch at a 1:1 ratio) or NS (hemodilution with saline 0.9% at a 3:1 ratio). Hemodilution was performed in animals of groups NS and HES in two stages, with target hematocrits 22% and 15%, achieved at 30-minute intervals. After two hours, 50% of the blood volume withdrawn was transfused and animals were monitored for another hour. Statistical analysis was based on ANOVA for repeated measures followed by multiple comparison test (P<0.05). Pearson's correlations were performed between changes in left ventricular end-diastolic volume (LVEDV) and PPV, central venous pressure (CVP) and pulmonary artery occlusion pressure (PAOP).

RESULTS

Group NS received a significantly greater amount of fluids during ANH (NS, 900 ± 168 mL vs. HES, 200 ± 50 mL, P<0.05) and presented greater urine output (NS, 2643 ± 1097 mL vs. HES, 641 ± 338 mL, P<0.001). Significant decreases in LVEDV were observed in group NS from completion of ANH until transfusion. In group HES, only increases in LVEDV were observed, at the end of ANH and at transfusion. Such changes in LVEDV (∆LVEDV) were better reflected by changes in PPV (∆PPV, R=-0.62) than changes in CVP (∆CVP, R=0.32) or in PAOP (∆PAOP, R=0.42, respectively).

CONCLUSION

Changes in preload during ANH were detected by changes in PPV. ∆PPV was superior to ∆PAOP and ∆CVP to this end.

Hemodynamic management of subarachnoid hemorrhage

Hemodynamic augmentation therapy is considered standard treatment to help prevent and treat vasospasm and delayed cerebral ischemia. Standard triple-H therapy combines volume expansion (hypervolemia), blood pressure augmentation (hypertension), and hemodilution. An electronic literature search was conducted of English-language papers published between 2000 and October 2010 that focused on hemodynamic augmentation therapies in patients with subarachnoid hemorrhage. Among the eligible reports identified, 11 addressed volume expansion, 10 blood pressure management, 4 inotropic therapy, and 12 hemodynamic augmentation in patients with unsecured aneurysms. While hypovolemia should be avoided, hypervolemia did not appear to confer additional benefits over normovolemic therapy, with an excess of side effects occurring in patients treated with hypervolemic targets. Overall, hypertension was associated with higher cerebral blood flow, regardless of volume status (normo- or hypervolemia), with neurological symptom reversal seen in two-thirds of treated patients. Limited data were available for evaluating inotropic agents or hemodynamic augmentation in patients with additional unsecured aneurysms. In the context of sparse data, no incremental risk of aneurysmal rupture has been reported with the induction of hemodynamic augmentation.

[True polycythemia: current views of pathogenesis, diagnostics and treatment]

Current concepts of true polycythemia are reviewed. Results of numerous epidemiological studies on the prevalence of this form of myeloproliferative neoplasms are presented with special reference to recent findings concerning its pathogenesis and the role of JAK2V617F mutation that occurs in the majority of patients. The clinical picture and new diagnostic criteria are discussed The data on the incidence and prevalence of the disease and its complications are considered including venous and/or arterial thrombosis, transformation into post-polycythemic myelofibrosis and acute myeloleucosis. An algorithm for the treatment of patients with erythremia is proposed along with recommendations on the use of aspirin, hydroxyurea, alpha-interpheron, and imatinib. The prospects for clinical application of selective JAK2 inhibitors are discussed.

Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage

BACKGROUND

Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution ("triple-H") therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy.

METHODS

A 43-item questionnaire was e-mailed to 375 members of the Neurocritical Care Society. Questions were designed to investigate the diagnostic approach to cerebral vasospasm and prophylactic and therapeutic administration of triple-H therapy.

RESULTS

Completed surveys were received from 167 respondents (45% response proportion). Eighty-six percent of respondents worked in hospitals with neurointensive care units (NICUs). SAH patients in hospitals with a NICU had longer ICU stay (P = 0.037) and had indwelling central venous catheters for longer (P < 0.01). Centers without dedicated NICUs were more likely to induce prophylactic hypervolemia (P < 0.01). Twenty seven percent of respondents (n = 45) reported using prophylactic hypervolemia in patients with SAH, while 100% reported inducing hypervolemia for severe or symptomatic vasospasm. Twelve percent (n = 20) of respondents reported inducing prophylactic hypertension, while all reported inducing hypertension with severe or symptomatic vasospasm. Half of respondents relied on the mean arterial pressure and half on systolic blood pressure as the clinical parameter for blood pressure titration. The most widely used agents to induce hypertension were phenylephrine (48%) and norepinephrine (39%). There was little variation in the use of hemodilution therapy comparing patients with or without evidence of vasospasm.

CONCLUSIONS

There are substantial differences in the administration of prophylactic triple-H, but there was high agreement on indication for therapeutic use. There was wide variability in the extent of ICU monitoring, diagnostic approach, physiologic parameters and values used as target of therapy. NICU availability was associated with more intensive monitoring. Lack of evidence and guidelines for triple-H therapy might largely explain these findings.

[Therapy of acute massive blood loss in a hemophilic patient: case report]

A case is reported of management of massive intraoperative blood loss in a male patient with severe hemophilia. Extirpation of hip pseudotumor with one-stage osteosynthesis with an intramedullary joint-pin in a 43 year old male patient was accompanied with 7.5 l blood loss. The infusion-transfusion therapy (ITT) contained transfusion media about 1/3 of the total volume, fresh-frozen plasma and erythrocyte-containing media were used 1:1. Infusion solutions consisted of balanced polyelectrolytic solutions, hydroxyethylated starches 130/0.4, hyperchaes. Intraoperative normovolemic hemodilution and reinfusion of wound blood were made (CellSaver). ITT target markers were standard hemodynamics control tests. Hemostasis monitoring was conducted with thromboelastography. Complex ITT based on modern principles of clinical transfusiology provided a complete and safe compensation of massive intraoperative blood loss in a patient with severe hemophilia.

[Hemodynamic correction in children with severe traumatic injuries by the means of transpulmonary hemodilution]

The purpose of the research is t objectify the indications for use of catecholamines and/or change of the infusion therapy volume based on transpulmonary thermodilution in children with severe traumatic injuries. The examined group consisted of 22 children with thermal concomitant or isolated trauma and drowning. All the patents were transferred to the Intensive Care Unit from other hospitals. Hemodynamic parameter estimation was based upon transpulmonary thermodilution. Results indicate, that based upon dynamic assessment of cardiac output, preload (global end diastolic volume index) and postload (systemic vascular resistance index) it is possible to carry out an early targeted correction of the fluid therapy and chose the right type of inotorpic support. Transpulmonary thermodilution in children with severe traumatic injuries allows achieving optimal parameters of blood circulation just 24 hours after its adaption.

["Low infusion resuscitation" in the treatment of wounded and injured with acute massive blood loss]

Acute massive blood loss (AMBL) of severe and extremely severe degree is still one of the leading causes of unfavourable traumatic disease. 95% of potentially preventable lethal outcomes in severe gunshot trauma is reported to depend largely on the adequacy of AMBL correction (Howard P., 2003). An alternate approach to the issue studied was the development of preparations of hyperosmotic saline solutions (7.5% sodium chloride) combined with hyperoncotic colloid solutions (dextrans, hetastarch). As a result, solutions were developed (so-called, hyperosmotic hyperoncotic volume expanders) allowing to achieve rapid and stable volemic and hemodynamic effect in case of low volume infusion (usually, 4 ml/kg of body weight). The present study allowed to conclude that "low infusion resuscitation" technique in patients with multiple trauma accompanied by acute massive blood loss of extremely severe degree enables to reduce lethality, to achieve early subcompesatory hemodynamic state in acute traumatic disease.

Effect of induced hypotensive anaesthesia vs isovolaemic haemodilution on blood loss and transfusion requirements in orthognathic surgery: a prospective, single-blinded, randomized, controlled clinical study

Induced hypotensive anaesthesia and isovolaemic haemodilution are well-established blood-sparing techniques in major surgery. This prospective study compared them for blood loss, transfusion requirements, and surgical field quality during standardized orthognathic operations. In a surgeon-blinded trial, 60 healthy patients requiring either Le Fort I osteotomy or bimaxillary surgery were randomly allocated to receive normotensive anaesthesia, induced hypotensive anaesthesia, or induced hypotensive anaesthesia combined with isovolaemic haemodilution. Blood loss and haemoglobin level were measured intraoperatively and calculated on postoperative day 3. The surgeons rated surgical field quality. Mean blood loss was 1021.63, 392.38 (p<0.05) and 1191.65ml in the normotensive, hypotensive and haemodilution groups, respectively. Mean haemoglobin level immediately after surgery was 9.3, 10.3, and 7.4g/dl (p<0.05), respectively. No hypotensive group patients received transfusions; four normotensive group patients required allogenic transfusions; seven haemodilution group patients needed autogenous retransfusions (p<0.05). Surgical field quality was significantly better in the hypotensive than in the normotensive (p<0.05) or haemodilution (p<0.05) groups. In orthognathic surgery, hypotensive anaesthesia significantly reduces blood loss and transfusion requirements and minimizes allogenic transfusions risks. Induced hypotensive anaesthesia combined with isovolaemic haemodilution has no additional blood-sparing effects but impairs surgical field quality.