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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
Guo JR, Shen HC, Liu Y, Xu F, Zhang YW, Shao Y, Su YJ
Hepato-Gastroenterology. 2015;62((140)):992-6.
Abstract
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.
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2.
Effect of acute normovolemic hemodilution combined with controlled low central venous pressure on cerebral oxygen metabolism of patients with hepalobectomy
Guo JR, Shen HC, Liu Y, Xu F, Zhang YW, Zhang JP, Yang DW
Hepato-Gastroenterology. 2014;61((136):):2321-5.
Abstract
BACKGROUND/AIMS: The effect of acute normovolemic hemodilution (ANH) combined with controlled low central venous pressure (LCVP) on the cerebral oxygen metabolism of patients with hepalobectomy. METHODOLOGY Undergoing hepatic resection operation in 60 cases, were randomly divided into control group, LCVP group (Group II) and ANH + LCVP group (Group IIl). Before hemodilution (T1), decrease of CVP (T2) and increase of CVP (T3) and at the end of surgery (T4), the blood was sampled via the jugular vein bulb and radial artery for blood gas analysis. RESULTS Compared with group I, the CaO2 of group II at T3 and T4 was increased; in group III, CaO2 and Da-jvO2 at T2 and T3 were decreased, CjvO2 at T2 decreased, and CaO2 and CjvO2 at T4 increased. Compared with group II, CaO2, CjvO2 and Da-jvO2 of group III at T2 and T3 were decreased. CERO2 of the three groups at T3 and T4 were all decreased (P<0.05 or 0.01). The jugular venous oxygen saturation (SjvO2) and VADL of the three groups at each time point were all within the normal range. CONCLUSION The moderate ANH combined with LCVP had no adverse effect on the cerebral oxygen metabolism of the patients with the hepalobectomy.
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3.
A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection
Jarnagin WR, Gonen M, Maithel SK, Fong Y, D'Angelica MI, Dematteo RP, Grant F, Wuest D, Kundu K, Blumgart LH, et al
Annals of Surgery. 2008;248((3):):360-9.
Abstract
BACKGROUND Hepatic resection is the most effective treatment for many malignant and benign conditions affecting the liver and biliary tree. Despite improvements, major partial hepatectomy can be associated with considerable blood loss and transfusion requirements. Transfusion of allogeneic blood products, although potentially life-saving, is associated with many potential complications. The primary aim of this study was to determine if acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces the requirement for allogeneic red cell transfusions in patients undergoing major hepatic resection. METHODS One hundred thirty patients undergoing major hepatic resection (> or =3 segments) were prospectively randomized to undergo either ANH or standard anesthetic management (STD). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8. 0 g/dL. Low central venous pressure anesthetic technique was used intraoperatively for both groups. A standardized transfusion protocol was applied to all patients intraoperatively and throughout the hospital stay. RESULTS From April 2004 to March 2007, 63 patients were randomized to ANH and 67 to STD. Demographics, diagnoses, liver function, extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, and length of hospital stay were similar between the 2 groups. ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD [12. 7% (n = 8) vs. 25. 4% (n = 17), respectively; P = 0. 067. ANH patients were less often transfused intraoperatively (n = 1, 1. 6%) compared with the STD group (n = 7, 10. 4%) (P = 0. 036), had higher postoperative hemoglobin levels (P = 0. 01), and tended to require fewer red cell units overall (28 vs. 47 units). In patients with intraoperative blood loss > or =800 mL, ANH reduced not only the allogeneic red cell transfusion rate (18. 2% vs. 42. 4%, P = 0. 045) but also the proportion of patients requiring fresh frozen plasma (21. 1% vs. 48. 3%, P = 0. 025). CONCLUSION For patients undergoing major liver resection, ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use. Given the modest transfusion rate in the STD arm, future efforts should attempt to target ANH use to patients most likely to benefit.
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4.
Acute normovolemic hemodilution combined with controlled hypotension in patients undergoing liver tumorectomy
Yao XH, Wang B, Xiao ZK, Zhou P, Chen CY, Qing ZH
Nan Fang Yi Ke Da Xue Xue Bao [Journal of Southern Medical University]. 2006;26((6):):828-30.
Abstract
OBJECTIVE To evaluate the effects of acute normovolemic hemodilution (ANH) combined with controlled hypotension on reducing heterogeneous transfusion and safety during liver tumorectomy. METHODS Thirty patients undergoing elective liver tumorectomy were randomly divided into 3 groups (10 each), namely ANH group (group A), ANH combined with controlled hypotension group (group B) and control group (group C). All the patients were anesthetized via endotracheal intubation. Before the operation, ANH was performed in groups A and B after anesthesia induction, and controlled hypotension was initiated in group B during tumorectomy. Blood transfusion and fluid infusion were carried out routinely in group C. Hb and Hct were measured before operation, after ANH, and immediately, 1 day and 7 days after the operation. The difference in intraoperative blood loss and heterogeneous blood transfusion volume in the 3 groups was observed. RESULTS In group A, heterogeneous blood transfusion was avoided in 6 cases and but given in the other cases for an average of 400 ml. In group C, every patient received heterogeneous blood transfusion (664. 8-/+248. 1 ml), but none of the patients received heterogeneous blood in group B. The difference in transfusion volume between the 3 groups was significant (P<0. 01). Hemodynamics was basically stable during operation in the 3 groups. CONCLUSION ANH combined with controlled hypotension is safe and effective for decreasing and even avoiding homologous blood transfusion in liver tumorectomy.
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5.
Prospective randomized controlled trial of acute normovolaemic haemodilution in major gastrointestinal surgery
Sanders G, Mellor N, Rickards K, Rushton A, Christie I, Nicholl J, Copplestone A, Hosie K
British Journal of Anaesthesia. 2004;93((6):):775-81.
Abstract
BACKGROUND The efficacy of acute normovolaemic haemodilution (ANH) remains uncertain because of a lack of well-designed prospective randomized controlled trials. The aim of this study was to assess the effects of ANH on allogeneic transfusion, postoperative complications, and duration of stay. METHODS Consecutive patients undergoing major gastrointestinal surgery were randomized to a planned 3-unit ANH, or no ANH. Both groups underwent identical management including adherence to a transfusion protocol after surgery. Outcome measures included the number of patients receiving allogeneic blood, complications, and duration of stay. RESULTS 380 patients were screened of which 160 were included in the study, median age was 62 yr (range 23-90), 'ANH' n=78, 'no ANH' n=82. There was no significant difference between groups in the number of patients receiving allogeneic blood 22/78 (28%) vs 25/82 (30%), the total number of allogeneic units transfused (90 vs 93), complication rate, or duration of stay. Haemodilution significantly increased anaesthetic time, median 55 (range 15-90) vs 40 min (range 17-80) (P<0. 001). Significantly fewer patients in the ANH group experienced oliguria in the immediate postoperative period 37/78 (47%) vs 55/82 (67%) (P=0. 012). The most significant factors affecting transfusion were blood loss, starting haemoglobin, and age. When compared with ASA-matched historical controls, the introduction of a transfusion protocol reduced the transfusion rate in colorectal patients from 136/333 (41%) to 37/138 (27%), P=0. 004. CONCLUSIONS In this large pragmatic study, ANH did not affect allogeneic transfusion rate in major gastrointestinal surgery. Preoperative haemoglobin, blood loss, and transfusion protocol are the key factors influencing allogeneic transfusion.
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6.
Effectiveness of acute normovolemic hemodilution to minimize allogeneic blood transfusion in major liver resections
Matot I, Scheinin O, Jurim O, Eid A
Anesthesiology. 2002;97((4):):794-800.
Abstract
BACKGROUND Liver resection is a major operation for which, even with the improvements in surgical and anesthetic techniques, the reported rate of blood transfusion was rarely less than 30%. About 60% of transfused patients require only 1 or 2 units of blood, a blood requirement that may be accommodated by the use of acute normovolemic hemodilution (ANH). METHODS The efficacy, hemodynamic effects, and safety of ANH were investigated in a randomized, active-control study in patients with American Society of Anesthesiologists status I-II who were undergoing major liver resection with fentanyl-nitrous oxide-isoflurane anesthesia. Patients were randomized to the ANH (n = 39) or control group (n = 39). Patients in the ANH group underwent hemodilution to a target hematocrit of 24%. The indication for blood transfusion was standardized. In both groups transfusion was started at a hematocrit of 20%. The primary efficacy endpoint was the avoidance of allogeneic blood transfusion in the intraoperative period and first 72 h after surgery. Various laboratory and hemodynamic parameters as well as postoperative morbidity were monitored to define the safety of ANH in this patient population. RESULTS During the perioperative period, 14 control patients (36%) received at least one unit of allogeneic blood compared with 4 patients (10%) in the ANH group ( < 0.05). The hemodilution process was not associated with significant changes in patients' hemodynamics. Morbidity was similar between the control and the ANH groups. Postoperative hematocrit levels and biochemical liver, renal, and standard coagulation test results were similar in both groups. CONCLUSIONS Acute normovolemic hemodilution in patients with American Society of Anesthesiologists status I-II undergoing major liver resection may allow a significant number of patients to avoid exposure to allogeneic blood.
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7.
A prospective randomised controlled trial of acute normovolaemic haemodilution (ANH) in major gastro-intestinal surgery and its effect on coagulation
Sanders G, Mellor NJ, Rickards K, Brodribb JA, Rushton AR, Christie I,, et al.,
Blood. 2002;100((11, Pt 2):):58a.. Abstract No. 209.
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8.
Acute normovolaemic haemodilution does not reduce allogeneic transfusion rate in major gastrointestinal surgery: a randomised controlled trial
Sanders G, Mellor NJ, Rickards K, Brodribb AJ, Rushton ARA, Christie I,, et al.,
British Journal of Haematology. 2002;117((Suppl 1):):3. Abstract No. 7.
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9.
Changes in coagulation physiology and rheology after preoperative normovolemic hemodilution . German
Hensel M, Wrobel R, Volk T, Pahlig H, Kox WJ
Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie. 1996;31((8):):481-7.
Abstract
AIM: In a prospective randomised controlled trial the effect of preoperative normovolaemic haemodilution on coagulation, plasma viscosity and plasma protein levels was examined. METHOD 50 patients undergoing gastrectomies were investigated (haemodilution group, n = 30; control group, n = 20). In the haemodilution group a haematocrit of 30% was aimed at. Blood was replaced by normovolaemic infusion of 6% hydroxyethyl starch 200/0.5. MAIN RESULTS Haematocrit, colloid osmotic pressure, total serum protein, serum albumin and platelet count were significantly decreased intra- and postoperatively in the haemodilution group compared with control group (p < 0.01). All of these showed no differences between the two groups on the 7th postoperative day. Global coagulation parameters showed dilutional influences without significant differences between the two groups. Measurements of rheological parameters showed a statistically significant decrease in plasma viscosity in the haemodilution group compared with control group (p < 0.01). Haemodilution led to a marked reduction in the use of homologous blood (1 unit/haemodilution group; 10 units/ control group). The average volume of 6% hydroxyethyl starch 200/0.5 administered per patient was 15.2 ml/kgKM/d (7.6-22.2 ml/kgKM/d) in the haemodilution group and 12.7 ml/ kgKM/d (8.4-17.7 ml/kgKM/d) in the control group. CONCLUSION Haemodilution induced decreases in plasma coagulation, platelet count and plasma proteins did not cause any functional impairement and may just reflect dilution of these parameters. It seems that infusion of 6% hydroxyethyl starch 200/0.5 in an amount of 10-20 ml/kgKM/d does not result in a relevant decrease in coagulation parameters.
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10.
Gelatin for volume replacement in hemodilution: hemodynamic study . Italian
Falchi S, Caresia C, Linden M, Vannucci F, Novelli GP
Minerva Anestesiologica. 1995;61((7-8):):299-305.
Abstract
OBJECTIVE To evaluate whether volume replacement with gelatine infusion with 3.5% urea bridges during normovolemic intentional hemodilution manages to stabilize hemodynamic parameters. EXPERIMENTAL DESIGN Randomized prospective study. SETTING Operating theatre for general surgery. PATIENTS ASA 1 and 2 patients undergoing major abdominal surgery. Criteria of admission: a) age < 70 years old; b) starting hematocrit > 30%; c) absence of coronary diseases or coagulative pathologies. INTERVENTIONS Blood lost during surgery was replaced with gelatine and crystalloid in a ratio of 1:1. Hemodynamic monitoring was performed by inserting an Opticath catheter in the pulmonary artery and the resulting data were processed using an Oximetrix computer. FINDINGS Oxygen transport (DO2), oxygen consumption (VO2) and heart rate (HR) were measured before the start of the operation and at the peak of hemodilution. RESULTS At times T0 = Hct 35 and T1 = Hct 28, studied parameters (DO2, VO2, HR) did not show statistically significant variations. CONCLUSIONS On the basis of the hemodynamic parameters studied gelatine was found to be an efficacious volume replacement solution during the course of moderate, intentional hemodilution.