Acute Normovolemic Hemodilution: A Practical Approach

Liana Maria Torres De Araújo, Luis Vicente Garcia

Faculty of Medicine, Hospital das Clínicas at Ribeir?o Preto, Ribeir?o Preto, Brazil.
Hospital das Clínicas at Ribeir?o Preto, Ribeir?o Preto, Brazil.

DOI: 10.4236/ojanes.2013.31011                

Abstract

Justifications: Perioperative allogeneic blood transfusion can be reduced or even completely avoided by using a set of different strategies: meticulous hemostasis, the use of pharmaceutical agents that assist in the process of coagulation/ fibrinolysis, the use of blood substitutes, induced hypotension, preoperative autologous blood donation, collection and reinfusion of autologous blood during the operation, as well as from acute normovolemic hemodilution (ANH). Contents: ANH consists of taking a percentage of the patient’s blood volume and a concurrent infusion of acellular fluids in order to maintain normovolemia. As a consequence, a hemodiluted patient will lose less blood cells for each blood volume that is lost during the surgical procedure. The aim of this study is to clarify doubts and provide practical information relative to the procedure of ANH through the author’s own experiences as well as literary examples. Conclusions: ANH is an easy and cheap technique performed during the intraoperative period useful to reduce the use of hemoderivatives.

Keywords

Hemodilution; Blood Transfusion; Anesthesia

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	L. T. Goodnough, “Acute Normovolaemic Haemodilution,” Vox Sanguinis, Vol. 83, No. 1, 2002, pp. 211-215. doi:10.1111/j.1423-0410.2002.tb05304.x
[2]	D. Murray, “Acute Normovolemic Hemodilution,” European Spine Journal, Vol. 13, No. 1, 2004, pp. 72-75. doi:10.1007/s00586-004-0755-8
[3]	A. Shander and T. S. Rijhwani, “Acute Normovolemic Hemodilution,” Transfusion, Vol. 44, No. 12, 2004, pp. 26S-34S. doi:10.1111/j.0041-1132.2004.04293.x
[4]	L. T. Goodnough and T. G. Monk, “Autologous Transfusion, Recombinant Factor VIIa, and Bloodless Medicine,” In: R. D. Miller, Ed., Miller’s Anesthesia, 7th Edition, 2009.
[5]	G. J. Crystal and M. R. Salem, “Hemodynamic Compensation during Acute Normovolemic Hemodilution,” Anesthesiology, Vol. 100, No. 4, 2004, pp. 1034-1035.
[6]	T. G. Monk, “Acute Normovolemic Hemodilution,” Anesthesiology Clinics North America, Vol. 23, No. 2, 2005, pp. 271-281. doi:10.1016/j.atc.2005.03.002
[7]	G. L. Bryson, A. Laupacis and G. A. Wells, “Does Acute Normovolemic Hemodilution Reduce Perioperative Allogeneic Transfusion? A Meta-Analysis,” Anesthesia and Analgesia, Vol. 86, No. 1, 1998, pp. 9-15.
[8]	J. C. Drummond, C. T. Petrovitch and T. A. Lane, “Hemostasis and Transfusion Medicine,” In: P. G. Barash, B. F. Cullen, R. K. Stoelting, M. K. Cahalan and M. C. Stock, Eds., Clinical Anesthesia, 6th Edition, 2009, pp. 369-410.
[9]	C. Lentschener and Y. Ozier, “Acute Normovolemic Hemodilution: The Subgroup of Patients Likely to Benefit Remains Uncertain,” Anesthesiology, Vol. 98, No. 6, 2003, p. 1519. doi:10.1097/00000542-200306000-00041
[10]	L. T. Goodnough, B. Skikne and C. Brugnara, “Erythropoietin, Iron and Erythropoiesis,” Blood, Vol. 96, No. 3, 2000, pp. 823-833.
[11]	I. Petra?ovicová, P. Sklienka, L. Kolár, J. Jahoda and R. Kula, “The Clinical Relevance of the Fluid Balance in Critically Ill Patients,” Critical Care, Vol. 4, No. 1, 2000, p. 19. doi:10.1186/cc739
[12]	M. Jamnicki, R. Kocian, P. vander Linden, M. Zaugg and D. R. Spahn, “Acute Normovolemic Hemodilution: Physiology, Limitations, and Clinical Use,” Journal of Cardiothoracic and Vascular Anesthesia, Vol. 17, No. 6, 2003, pp. 747-754. doi:10.1053/j.jvca.2003.09.018
[13]	P. G. Loubser and A. Chan, “Prediction of the Effect of Acute Normovolemic Hemodilution on the Hematological Constituents of Sequestered Autologous Whole Blood,” Anesthesia and Analgesia, Vol. 102, No. 4, 2006, pp. 991-997. doi:10.1213/01.ane.0000198700.41026.2e
[14]	G. Singbartl, K. Singbartl and W. Schleinzer, “Is Acute Normovolemic Hemodilution Cost-Effective?” Transfusion, Vol. 36, No. 9, 1996, pp. 849-850. doi:10.1046/j.1537-2995.1996.36996420770.x
[15]	P. Innerhofer, D. Fries, A. Klingler and W. Streif, “In Vivo Effect of Haemodilution with Saline on Coagulation,” British Journal of Anaesthesia, Vol. 89, No. 6, 2002, pp. 934-939. doi:10.1093/bja/aef574
[16]	L. T. Goodnough, T. G. Monk and M. E. Brecher, “Acute Normovolemic Hemodilution Should Replace the Preoperative Donation of Autologous Blood as a Method of Autologous-Blood Procurement,” Transfusion, Vol. 38, No. 5, 1998, pp. 473-476. doi:10.1046/j.1537-2995.1998.38598297217.x
[17]	D. A. Henry, P. A. Carless, A. J. Moxey, D. O’Connell, M. A. Forgie, P. S. Wells and D. Fergusson, “Preoperative Autologous Donation for Minimising Perioperative Allogeneic Blood Transfusion,” Cochrane Database of Systematic Reviews, No. 2, 2002, Article ID: CD003602.
[18]	S. Hill, P. A. Carless, D. A. Henry, J. L. Carson, P. P. C. Hebert, K. M. Henderson and B. McClelland, “Transfusion Thresholds and Other Strategies for Guiding Allogeneic Red Blood Cell Transfusion,” Cochrane Database of Systematic Reviews, No. 1, 2000, Article ID: CD002042. doi:10.1002/14651858.CD002042
[19]	L. Davies, T. J. Brown, S. Haynes, K. Payne, R. A. Elliott and C. McCollum, “Cost-Effectiveness of Cell Salvage and Alternative Methods of Minimising Perioperative Allogeneic Blood Transfusion: A Systematic Review and Economic Model,” Health Technology Assessment, Vol. 10, No. 44, 2006, pp. 1-210.
[20]	K. Singbartl, P. Innerhofer, J. Radvan, B. Westphalen, D. Fries, R. Stogbauer and H. Van Aken, “Hemostasis and Hemodilution: A Quantitative Mathematical Guide for Clinical Practice,” Anesthesia and Analgesia, Vol. 96, No. 4, 2003, pp. 929-935. doi:10.1213/01.ANE.0000052711.68903.5D
[21]	C. Madjdpour and D. R. Spahn, “Allogeneic Red Blood Cell Transfusions: Efficacy, Risks, Alternatives and Indications,” British Journal of Anaesthesia, Vol. 95, No. 1, 2005, pp. 33-42. doi:10.1093/bja/aeh290
[22]	J. B. Gross, “Estimating Allowable Blood Loss: Corrected for Dilution,” Anesthesiology, Vol. 58, No. 3, 1983, pp. 277-280. doi:10.1097/00000542-198303000-00016
[23]	S. B. Jones, C. W. Whitten and T. G. Monk, “Influence of Crystalloid and Colloid Replacement Solutions on Hemodynamic Variables during Acute Normovolemic Hemodilution,” Journal of Clinical Anesthesia, Vol. 16, No. 1, 2004, pp. 1-17. doi:10.1016/j.jclinane.2003.03.003
[24]	D. S. Prough and A. Bidani, “Hyperchloremic Metabolic Acidosis Is a Predictable Consequence of Intraoperative Infusion of 0.9% Saline,” Anesthesiology, Vol. 90, No. 5, 1999, pp. 1247-1249. doi:10.1097/00000542-199905000-00003
[25]	E. L. Williams, K. L. Hildebrand, A. S. McCormick and M. J. Bedel, “The Effect of Intravenous Lactated Ringer’s Solution versus 0.9% Sodium Chloride Solution on Serum Osmolality in Human Volunteers,” Anesthesia and Analgesia, Vol. 88, No. 5, 1999, pp. 999-1003.
[26]	D. A. Otsuki, D. T. Fantoni, C. B. Margarido, C. K. Marumo, T. Intelizano, C. A. Pasqualucci and J. O. C. Auler Junior, “Hydroxyethyl Starch Is Superior to Lactated Ringer as a Replacement Fluid in a Pig Model of Acute Normovolaemic Haemodilution,” British Journal of Anaesthesia, Vol. 98, No. 1, 2007, pp. 29-37. doi:10.1093/bja/ael312
[27]	L. M. T. Araújo, “Hemodilui??o normovolêmica com so lu??o hipert?nica a 7.5%. Parametros hemodinamicos, efeitos metabólicos e repercuss?es laboratoriais,” Ph.D. Dissertation, Faculdade de Medicina de Ribeir?o Rreto, Ribeir?o Preto, 2008.
[28]	D. Drobin and R. G. Hahn, “Efficiency of Isotonic and Hypertonic Crystalloid Solutions in Volunteers,” Anesthesiology, Vol. 96, No. 6, 2002, pp. 1371-1380. doi:10.1097/00000542-200206000-00016
[29]	D. J. Ciesla, E. E. Moore, R. J. Musters, W. L. Biffl and C. C. Silliman, “Hypertonic Saline Alteration of the PMN Cytoskeleton: Implications for Signal Transduction and the Cytotoxicity Response,” Journal of Trauma, Vol. 50, No. 2, 2001, pp. 206-212. doi:10.1097/00005373-200102000-00004
[30]	J. A. Kolsen-Petersen, “Immune Effect of Hypertonic Sa line: Fact or Fiction?” Acta Anaesthesiologica Scandinavica, Vol. 48, No. 6, 2004, pp. 667-678. doi:10.1111/j.1399-6576.2004.00396.x
[31]	J. F. Feldman, J. V. Roth and D. G. Bjoraker, “Maximum Blood Savings by Acute Normovolemic Hemodilution,” Anesthesia and Analgesia, Vol. 80, No. 1, 1995, pp. 108 113.
[32]	O. P. Habler, M. S. Kleen, J. W. Hutter, A. H. Podtschaske, M. Tiede, G. I. Kemming, M. V. Welte, C. O. Corso, S. Batra, P. E. Keipert, N. S. Faithfull and K. F. Messmer, “Does Acute Normovolemic Hemodilution Reduce Perioperative Allogeneic Transfusion? A Meta-Analysis. The International Study of Perioperative Transfusion,” Anesthesia and Analgesia, Vol. 86, No. 1, 1998, pp. 9-15.
[33]	J. B. Segal, E. Blasco-Colmenares, E. J. Norris and E. Guallar, “Preoperative Acute Normovolemic Hemodilution: A Meta-Analysis,” Transfusion, Vol. 44, No. 5, 2004, pp. 632-644. doi:10.1111/j.1537-2995.2004.03353.x
[34]	A. Trouwborst, J. van Bommel, C. Ince and C. P. Henny, “Monitoring Normovolaemic Haemodilution,” British Journal of Anaesthesia, Vol. 81, Suppl. 1, 1998, pp. 73-78.
[35]	M. Gohel, R. Bulbulia, F. Slim, K. Poskitt and M. Why man, “How to Approach Major Surgery Where Patients Refuse Blood Transfusion (Including Jehovah’s Witnesses),” Annals of the Royal College of Surgeons of England, Vol. 87, No. 1, 2005, pp. 3-14. doi:10.1308/1478708051414
[36]	L. Milligan and M. Bellamy, “Anaesthesia and Critical Care of Jehovah’s Witnesses. Continuing Education in Anaesthesia,” Critical Care & Pain, Vol. 4, No. 2, 2004, pp. 35-39.
[37]	M. K. Viele and R. B. Weiskopf, “What Can We Learn about the Need for Transfusion from Patients Who Refuse Blood? The Experience with Jehovah’s Witness,” Transfusion, Vol. 34, No. 5, 1994, pp. 396-401. doi:10.1046/j.1537-2995.1994.34594249050.x
[38]	E. C. M. S. Van Woerkens, A. Trouwborst and J. J. B. van Lanschot, “Profound Hemodilution: What Is the Critical Level of Hemodilution at Which Oxygen Delivery-Dependent Oxygen Consumption Starts in an Anesthetized Human?” Anesthesia and Analgesia, Vol. 75, No. 5, 1992, pp. 818-821.
[39]	S. Kahraman, K. H. Altunkaya, B. Celebioglu, M. Kanbak, I. Pasaoglu and K. Erdem, “The Effect of Acute Nor movolemic Hemodilution on Homologous Blood Requirements and Total Estimated Red Blood Cell Volume Lost,” Acta Anaesthesiolica Scandinavica, Vol. 41, No. 5, 1997, pp. 614-617. doi:10.1111/j.1399-6576.1997.tb04752.x
[40]	M. Jacob, D. Bruegger, P. Conzen, B. F. Becker, U. Finsterer and M. Relum, “Development and Validation of a Mathematical Algorithm for Quantifying Preoperative Blood Volume by Means of the Decrease in Hematocrit Resulting from Acute Normovolemic Hemodilution,” Transfusion, Vol. 45, No. 4, 2005, pp. 562-571. doi:10.1111/j.0041-1132.2005.04292.x
[41]	R. B. Weiskopf, “Efficacy of Acute Normovolemic He modilution Assessed as a Function of Fraction of Blood Volume Lost,” Anesthesiology, Vol. 94, No. 3, 2001, pp. 439-446. doi:10.1097/00000542-200103000-00013
[42]	A. Shander and L. T. Goodnough, “Objectives and Limitations of Bloodless Medical Care,” Current Opinion in Hematology, Vol. 13, No. 6, 2006, pp. 462-470. doi:10.1097/01.moh.0000245692.32085.bd