Selecting patients for acute normovolemic hemodilution during hepatic resection: A prospective randomized evaluation of nomogram-based allocation
Frankel TL, Fischer M, Grant F, Krone J, D'Angelica MI, Dematteo RP, Jarnagin WR, Gonen M
Journal of the American College of Surgeons. 2013;217((2):):210-20.
BACKGROUND Acute normovolemic hemodilution (ANH) decreases transfusion rates but adds to the complexity of anesthetic management during hepatectomy. A randomized controlled trial was conducted to determine if selecting patients for ANH using a transfusion nomogram improves management and resource use compared with selection using extent of resection. STUDY DESIGN One hundred fourteen patients undergoing partial hepatectomy were randomized to a clinical arm (ANH used for resection of >=3 liver segments) or a nomogram arm (ANH used for predicted probability of transfusion >=50% based on a previously validated nomogram). The primary end point was appropriate management, defined as avoidance of ANH in patients at low risk or use of ANH in patients at high risk for allogeneic red blood cell transfusions. RESULTS Between September 2009 and May 2011, 58 patients were randomized to the clinical arm and 56 to the nomogram arm. Demographics, diagnoses, extent of resection, blood loss, and incidence and grade of complications did not differ between the 2 groups. There were no differences in perioperative transfusions or laboratory values. Nomogram-based allocation did not change appropriate management overall (80% vs 76% in the clinical arm; p=0.65), but did result in comparable perioperative outcomes and a trend toward decreased ANH use (30% vs 47%; p= 0.09), particularly in low blood loss (estimated blood loss <=400mL) cases (12% vs 25%; p= 0.04). CONCLUSIONS Although allocation of intraoperative management using a transfusion nomogram did not improve appropriate management overall, it more effectively identified low blood loss cases and reduced ANH use in patients least likely to benefit. Copyright 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.