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Abstract Postoperative anemia is a complex clinical issue that requires attention due to its ramifications on the patient's recovery and prognosis. Originating from multiple determinants, such as intraoperative blood loss, hemolysis, nutritional deficiencies, systemic inflammation and impact on the bone marrow, postoperative anemia has varied and often challenging presentations. Patients undergoing major surgical procedures, in particular, are susceptible to developing anemia due to the considerable associated blood loss. Accurate diagnosis plays a crucial role in the approach, requiring meticulous hematological analysis, including hemoglobin, hematocrit and reticulocyte count, as well as an in-depth investigation of the underlying causes. An additional challenge arises in the form of the excessive practice of phlebotomy during hospitalization for clinical monitoring. Although it is essential to assess the progression of anemia, frequent removal of blood may contribute to iatrogenic anemia, further delaying recovery and possibly increasing susceptibility to infection.
Subject(s)
Anemia , Blood Transfusion , ErythropoietinABSTRACT
Abstract Autologous blood transfusion can be achieved through different techniques, including by the patient donating blood before surgery (pre-deposit), collecting blood from the patient immediately before the operation and replacing the volume with colloids or plasma expanders (acute normovolemic hemodilution) or through the salvage of lost blood, during or immediately after surgery, and its retransfusion after washing (intraoperative or postoperative recovery). We will focus on the two methods used intraoperatively that are of fundamental importance in the management and conservation of the patient's own blood.
Subject(s)
Hemodilution , Thoracic SurgeryABSTRACT
RESUMEN La anemia durante la gestación es considerada un problema de salud pública debido a las prevalencias alarmantes que se presentan a nivel mundial. La medida optada por los diversos gobiernos es la administración masiva con suplementos de hierro. Sin embargo, actualmente existe evidencia contradictoria sobre el consumo de hierro, el exceso de su consumo y los potenciales riesgos durante la gestación tanto para la madre como para el producto. Para la gestación se requiere de 1 gramo adicional de hierro para la madre, el feto, la placenta y el parto. Esto genera un aumento de la masa roja del 20%; pero, para evitar la hemoconcentración el volumen plasmático se expande casi el 50%, generando una hemodilución fisiológica. Para la gestante no se ha establecido un criterio que permita diferenciar la anemia por deficiencia de hierro, de la anemia fisiológica debido al proceso normal de hemodilución. En el caso de Perú y de países con población residente de altura, se suma una problemática adicional, el factor de corrección de hemoglobina por residencia en la altura, el cual es un valor determinado de forma matemática y arbitraria. Las evidencias recientes sugieren que este factor debe ser reevaluado, debido a que no considera la etnia y el tiempo generacional de residencia en la altura. La presente revisión muestra una actualización y discusión de los criterios de diagnóstico de anemia, la suplementación con hierro, el factor de corrección de hemoglobina por altura de residencia y el impacto de la contaminación ambiental sobre el proceso de gestación.
ABSTRACT Anemia during pregnancy is considered a public health problem, due to the alarming prevalence worldwide. The measure chosen by various governments is massive iron supplements. However, there is currently contradictory evidence on iron intake, excess consumption, and potential risks during pregnancy for both the mother and child. For gestation, an additional 1 gram of iron is required for the mother, fetus, placenta, and delivery. This generates an increase in red mass of 20% but to avoid hemoconcentration the plasma volume expands by almost 50% generating a physiological hemodilution. For pregnant women, no criteria have been established to differentiate iron deficiency anemia and physiological anemia due to the normal process of hemodilution. In the case of Peru and countries with high altitude resident population, there is an additional problem, the hemoglobin correction factor for high altitude residence, which is a mathematically and arbitrarily determined value. Recent evidence suggests that this factor should be reevaluated because it does not consider ethnicity and generational time of residence at high altitude. The present review provides an update and discussion of the diagnostic criteria for anemia, iron supplementation, the hemoglobin correction factor for altitude of residence, and the impact of environmental pollution on the gestation process.
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To investigate the changes of anesthetic drug concentration in plasma during isolation of autologous blood with acute normovolemic hemodiluti-on and its influence on the depth of anesthesia, muscle relaxant effect and blood drug concentration after reinfusion. METHODS: Forty patients of both sexes, aged 20-60 yr, American Society of Anesthesiologists physical status or Ⅱ, hemoglobin (Hb) >120 g / L, hematocrit (Hct) >35%, undergoing eletive multilevel spinal surgery were included, were divided into 2 groups (n=20 each) using a random number table. ANH group (group A): ANH was performed after stable induction of anesthesia, the target Hct value was 28%-30%, and autologous blood was reinfused after the main operation steps. Control group (group C): routine transfusion and infusion treatment. The bispectral index (BIS) and Train-of-Four stimulation (TOF) were observed and recorded at the stable induction of anesthesia (T1), 30 minutes of stable induction (T2), the end of operation (T3), 30 minutes after the end of the operation (T4), 1 hour after the end of the operation (T5) and 2 hours after the end of the operation (T6). The concentrations of propofol and cisatracurium besylate in plasma at T1-T6, stored blood at 1 h (TS1), 2 h (TS2), and before reinfusion (TS3) were detected by Liquid Chromatography-tandem Mass Spectrometry. The extubation time and recovery score at T4-6 hours were recorded. RESULTS: There was no significant difference in propofol between the two groups at each time point (P > 0.05). The plasma concentration of cisatracurium besylate in group A was higher than that in group C at T3 (P0.05). The BIS value at T4 and TOF value at T3 in group A were significantly lower than those in group C. The recovery score of group A was lower than that of group C at T4 (P0.05). CONCLUSION: The plasma concentrations of propofol and cisatracurium besylate were basically unchanged during the in vitro isolation of ANH autologous blood. The plasma concentrations of cisatracurium besylate were only temporarily affected after the main operation steps, but the postoperative muscle relaxation recovery and recovery quality were not significantly affected.
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【Objective】 To explore the effects of acute normovolemic hemodilution (ANH) combined with intraoperative recycled autotransfusion on blood transfusion volume and coagulation function in elderly patients undergoing cardiac surgery. 【Methods】 A total of 94 elderly patients undergoing cardiac surgery in the hospital were enrolled and randomly divided into observation group (n=47) and control group (n=47) between March 2020 and March 2022. The observation group was given ANH combined with intraoperative recycled autotransfusion, while control group was given routine allogeneic transfusion. The blood transfusion volume, oxygenation status, immune function, inflammatory indexes and adverse reactions in the two groups were compared. 【Results】 The banked blood transfusion volume was less in observation group than control group [(1.73±0.43) U vs (5.71±1.71) U, P<0.05]. At 6 h after surgery, blood oxygen saturation (SvO2) level was higher [(74.59±7.20) % vs (67.22±6.19) %], while oxygen uptake rate (ERO2) level was lower[(0.29±0.06) % vs (0.34±0.05) %] in observation group than control group (P<0.05). At day 1 after surgery, levels of CD3+, CD4+, CD4+ /CD8+ and natural killer cells (NK) were higher [(65.11±5.14) %, (46.93±5.17) %, (1.86±0.30), (8.35±1.23) % vs (57.45±7.24) %, (43.58±4.85) %, (1.47±0.36)%, (7.34±1.38) %], while CD8+ was lower [(25.17±4.01) % vs (30.39±5.06) %] in observation group than control group (P<0.05). At day 1 after surgery, levels of serum interleukin 6/8 (IL-6/8) and tumor necrosis factor-α (TNF-α) were lower in observation group than control group [(104.51±12.55) ng/L vs (125.81±14.96) ng/L, (351.42±52.86) ng/L vs (394.27±55.78) ng/L, (254.93±49.94) ng/L vs (323.60±52.63) ng/L, P<0.05]. The incidence of adverse reactions was lower in observation group than control group (4.26% vs 17.02%), P<0.05. 【Conclusion】 Recycled autotransfusion can reduce allogeneic transfusion volume in elderly patients undergoing cardiac surgery. There is no difference in the effects on blood routine or coagulation function between recycled autotransfusion and allogeneic transfusion. Compared with allogeneic transfusion, recycled autotransfusion can significantly improve oxygenation status, relieve immunosuppression and inflammation response, and reduce the risk of adverse reactions.
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Resumen: Introducción: El impacto en el sistema inmunitario de la hemodilución normovolémica como técnica de ahorro hemático perioperatoria plantea un posible aumento de la inmunoglobulina M, y un factible incremento de las infecciones, sobre todo de las asociadas a catéteres. Objetivo: Comparar el papel de la hemodilución normovolémica aguda en infecciones postoperatorias en pacientes sometidos a cirugía cardíaca. Material y métodos: Se realizó un ensayo clínico controlado, en el que se incluyeron 99 pacientes sometidos a cirugía cardíaca electiva que se distribuyeron de manera aleatoria en dos grupos: grupo I (no hemodiluidos) o grupo II (hemodiluidos) y durante el período postoperatorio mediato se determinó la presencia o no de infección. Para el análisis de variables se utilizó estadística descriptiva e inferencial mediante χ2. Una p < 0.05 fue significativa. Los datos fueron procesados en SPSS statistics 25.0. Resultados: La incidencia global de infección fue 3.03%. Los pacientes hemodiluidos se infectaron más que los no hemodiluidos (p = 0.045). Los organismos aislados fueron Escherichia coli (66.6%) y Enterobacter aerogenes (3.33%). Conclusión: Los pacientes sometidos a cirugía cardíaca a quienes se les practica hemodilución normovolémica aguda, presentan más infecciones postoperatorias en comparación con los que no se les aplica.
Abstract: Introduction: The impact on the immune system of normovolemic hemodilution as a perioperative blood-saving technique raises a possible increase in immunoglobulin M, and a possible increase in infections, especially those associated with catheters. Objective: To compare the role of acute normovolemic hemodilution in postoperative infections in groups of patients undergoing cardiac surgery. Material and methods: A controlled clinical trial in 99 patients undergoing elective cardiac surgery who were randomized into two groups: group I (non-hemodiluted) and group II (hemodiluted). The presence or absence of infection was determined during the postoperative period. Data analysis was performed using descriptive and inferential statistics χ2. A p < 0.05 was considered significant. The data were processed using SPSS v.25.0. Results: The overall incidence of infection was 3.03%. Hemodiluted patients became infected more frequently than non-hemodiluted patients. The isolated organisms were Escherichia coli and Enterobacter aerogenes. Conclusion: Patients undergoing cardiac surgery who undergo acute normovolemic hemodilution suffer more frequently from postoperative infections than those who do not undergo acute normovolemic hemodilution.
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Objective:The study aimed to evaluate the effect of mild and moderate hemodilution during CPB on the neurocognitive dysfunction in patients undergoing coronary artery bypass grafting. Design: A randomized clinical study. Setting: Cardiac center. Patients: 186 patients scheduled for cardiac surgery with cardiopulmonary bypass. Intervention: The patients were classified into 2 groups (each = 93), Mild hemodilution group: The hematocrit value was maintained >25% by transfusion of packed?red blood cells plus hemofiltration during CPB. Moderate hemodilution group: the hematocrit value was maintained within the range of 21?25%. Measurements: The monitors included the hemofiltrated volume, number of transfused packed red blood cells, and the incidence of postoperative cognitive dysfunction. Main Results: The hemofiltrated volume during CPB was too much higher with mild hemodilution compared to the moderate hemodilution (p = 0.001). The number of the transfused packed red blood cells during CPB was higher with mild hemodilution compared to the moderate hemodilution (p = 0.001), but after CPB, the number of the transfused packed red blood cells was lower with the mild hemodilution group than the moderate hemodilution (p = 0.001). The incidence of total postoperative neurological complications was significantly lower with the mild hemodilution group than moderate hemodilution (p = 0.033). The incidence of neurocognitive dysfunction was significantly lower with mild hemodilution group than moderate hemodilution (p = 0.042). Conclusions: The mild hemodilution was associated with a significant decrease in the incidence of neurocognitive dysfunction compared to moderate hemodilution in patients undergoing coronary artery bypass grafting. Also, the transfused packed red blood cells increased during CPB and decreased after CPB with the mild hemodilution than moderate hemodilution.
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AIM: To observe the effect of acute normovolemic hemodilution (ANH) autologous blood transfusion on the EEG bispectral index and muscle relaxation in elderly patients undergoing orthopedic surgery to explore the influence of autologous blood transfusion containing anesthetic components on the quality and safety of postoperative anesthesia recovery. METHODS: Forty patients, aged 65-75, weighing 55-80 kg, ASA grade I-II, with an estimated intraoperative blood loss of more than 600 mL, were selected for elective orthopedic surgery. The patients were randomly divided into two groups (n=20): group A was given acute normovolemic hemodilution (ANH), and the target value of Hct was 28%-30% after induction of anesthesia; group B was the control group which was given routine fluid infusion during operation without ANH. Bispectral index (BIS), TOF values and plasma concentrations of propofol and cisatracurium were measured at the beginning of autotransfusion (T
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Objective:To investigate the effect of acute hypervolemic hemodilution (AHH) with 6% hydroxyethyl starch 130/0.4 on pharmacodynamics of propofol during successful laryngeal mask airway (LMA) implantation.Methods:American Society of Anesthesiology physical status Ⅰ or Ⅱ patients, aged 30-60 yr, with body mass index of 18.5-25.0 kg/m 2, undergoing elective extensive total hysterectomy under general anesthesia, were divided into 2 groups: AHH group (group A) and control group (group C). In group A, 6% hydroxyethyl starch 130/0.4 was infused at a rate of 20 ml/min for AHH, and the target hematocrit was 30%.In group C, lactated Ringer′s solution was infused according to the " 4-2-1" rule to supplement physiological requirements, and anesthesia induction was performed after 10 min of stabilization.Sufentanil was administered by target-controlled infusion using Bovil pharmacokinetic model with effect-site concentration (Ce) of 0.25 ng/ml, 3 min later propofol was given by target-controlled infusion using Schnider model.The Ce of propofol in the first patient was set at 5.0 μg/ml.Each time the concentration of propofol was increased/decreased by 0.5 μg/ml according to the sequential method.LMA was inserted following 1 min equilibration between plasma concentration and Ce of propofol.The trial was terminated when 8 consecutive inflection points of failed/successful LMA insertion occurred.The EC 5, EC 50, EC 95 and 95% confidence interval (95% CI) of propofol were calculated by probit regression analysis. Results:In group A, the EC 5 (95% CI), EC 50 (95% CI) and EC 95 (95% CI) of propofol when LMA was successfully placed were 4.237 (3.090-4.514) μg/ml, 4.802 (4.500-5.078) μg/ml and 5.443 (5.125-7.304) μg/ml, respectively.In group C, the EC 5 (95% CI), EC 50 (95% CI) and EC 95 (95% CI) of propofol when LMA was successfully placed were 2.408 (1.190-2.756) μg/ml, 3.120 (2.690-3.472) μg/ml and 4.042 (3.582-7.431) μg/ml, respectively.There was significant difference in EC 5, EC 50 and EC 95 between the two groups ( P<0.01). Conclusion:AHH with 6% hydroxyethyl starch 130/0.4 can decrease the efficacy of propofol when LMA is successfully implanted.
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Abstract Background and objectives: The study assessed the role of acute hemodilution in the blood transfusion rate in patients submitted to surgical treatment of scoliosis. Methods: Retrospective observational study performed at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC-FMRP-USP). Medical charts of patients submitted to elective correction of scoliosis between January 1996 and December 2016 were analyzed. Variables assessed were: age, weight, sex, presence of comorbidities, data regarding anesthesia and surgery, lab data, adverse events and blood transfusion rate. The final sample consisted of 33 procedures performed by the same anesthesiologist and same surgeon, divided into two groups: Hemodilution Group (n = 16) and Control Group (n = 17). Indication of acute normovolemic hemodilution was determined by patient refusal of blood transfusion for religious reasons. Results: The sample was statistically homogeneous and the groups were compared in terms of the attributes analyzed. The volume of homologous blood used by the Hemodilution Group was significantly lower than the Control Group (p = 0.0016). The percentage of patients who required transfusion was 12.5% in the Hemodilution Group, while it was 70.69% (p = 0.0013) in the Control Group. Upon hospital discharge, mean values of hemoglobin and hematocrit between groups did not present significant differences (p = 0.0679; p = 0.1027, respectively). Conclusions: Acute normovolemic hemodilution, in scoliosis correction surgeries, reduces blood transfusion rates, meeting patient needs without increasing adverse events or infection rates.
Resumo Justificativa e objetivos: Este estudo avaliou o papel da hemodiluição aguda na taxa de transfusão sanguínea em pacientes submetidos a tratamento cirúrgico de escoliose. Método: Estudo observacional retrospectivo realizado no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HCFMRP/USP). Analisados prontuários de pacientes submetidos à correção de escoliose no período entre janeiro de 1996 a dezembro de 2016, em regime eletivo. As variáveis avaliadas foram: idade, peso, sexo, presença de doenças concomitantes, dados referentes à anestesia e à cirurgia, dados laboratoriais, eventos adversos e taxa de transfusão sanguínea. A amostra final foi composta por 33 procedimentos realizados pelo mesmo médico anestesiologista e pelo mesmo cirurgião, divididos em dois grupos: Grupo Hemodiluição (n = 16) e Grupo Controle (n = 17). A indicação de hemodiluição normovolêmica aguda foi determinada pela recusa à transfusão sanguínea pelos pacientes, por motivos religiosos. Resultados: A amostra foi estatisticamente homogênea e os grupos foram comparados considerando os atributos analisados. O volume de sangue homólogo utilizado pelo Grupo Hemodiluição foi significativamente menor que no Grupo Controle (p = 0,0016). A porcentagem de pacientes que necessitou transfusão foi de 12,5% no grupo Hemodiluição, enquanto no Grupo Controle foi de 70,69% (p = 0,0013). Na alta hospitalar, os valores médios de hemoglobina e hematócrito entre os grupos não apresentaram diferenças significantes (p = 0,0679; p = 0,1027, respectivamente). Conclusões: A hemodiluição normovolêmica aguda, em cirurgias para correção de escoliose, reduz a taxa de transfusão sanguínea, satisfazendo as necessidades dos pacientes sem aumentar as taxas de eventos adversos e de infecção.
Subject(s)
Scoliosis/surgery , Blood Transfusion/statistics & numerical data , Hemodilution/methods , Retrospective StudiesABSTRACT
Perioperative autotransfusion and blood protection has become a hot issue in modern medicine. Hemodilution, as an effective method of saving blood, has been widely used in clinical practice. It can reduce the clinical demand for allogeneic blood source and relieve the tension of clinical blood use to a certain extent. However, hemodilution itself will also have a certain impact on human physiological functions; especially it can affect the pharmacokinetics and pharmacodynamics of anesthetics and the depth of anesthesia. This paper focuses on the effects of hemodilution on anesthetics and anesthesia depth.
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Iron is essential for health; its deficiency and excess are harmful. Our bodies have a high capacity to store and reuse iron so that its requirement is small (1-2 mg absorbed/day). Hepcidin, a hormone produced in the liver, has an important role in this elements homeostasis by blocking its transport protein, inhibiting its absorption in the duodenum and its release from the iron stores. During pregnancy, there is a new iron requirement for the placenta and fetus. This causes an increase in erythropoiesis; however, hemoglobin concentration decreases due to the greater vascular expansion. This results in hemodilution, which is evident starting the second trimester and returns to pre-gestational values at the end of the third trimester. Maternal iron deficiency anemia becomes a public health problem when it is moderate (7-14,5 g/dL) during pregnancy adversely affect the mother and neonate. For this reason, it is important to confirm if a pregnant woman with low hemoglobin levels is anemic or if it is due to hemodilution, a physiological process during pregnancy that does not require treatment. This review presents evidence to distinguish anemia from physiological hemodilution.
El hierro es un micronutriente fundamental para la salud; su deficiencia o su exceso son dañinos. Por ello, el organismo regula el requerimiento de hierro en base a su alta capacidad para almacenar y reciclar el hierro corporal de tal manera que su requerimiento es mínimo (1 a 2 mg absorbido/día). Esto se regula a través de la hepcidina, una hormona hepática que inhibe a la proteína transportadora de hierro (ferroportina) y con ello disminuye la absorción de hierro, o su liberación en los tejidos donde se almacenan. Durante la gestación hay una mayor necesidad de hierro para la placenta y el feto, y ello se evidencia en un aumento de la eritropoyesis; sin embargo, la concentración de la hemoglobina disminuye por efecto de una mayor expansión vascular. Esto determina una hemodilución que se evidencia a partir del segundo trimestre, y luego se va normalizando al final del tercer trimestre. La anemia materna por deficiencia de hierro se constituye en un problema de salud pública cuando es de magnitud moderada (7 a 14,5 g/dL) en la gestante afecta a la madre y al neonato. Por ello es importante determinar si una gestante con hemoglobina baja es realmente anémica o tiene una hemodilución, que es un proceso fisiológico que no requiere de tratamiento. Esta revisión presenta las evidencias para poder discriminar entre una anemia verdadera gestacional de una hemodilución fisiológica.
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Abstract Objective To prospectively compare the clinical and laboratorial aspects of patients undergoing spine deformity surgery, using the acute normovolemic hemodilution technique with tranexamic acid, versus a control group with tranexamic acid alone, and to evaluate the influence of hemodilution in intraoperative bleeding and the need for homologous transfusion. Materials and Methods Comparative prospective study with patients aged between 12 and 65 years undergoing spine deformity surgery with the acute normovolemic hemodilution technique associated with tranexamic acid versus a control group to which only tranexamic acid (15 mg/kg) was administered. Laboratorial exams were performed and analyzed in three different moments. Results A total of 30 patients were included in the present study: 17 in the hemodilution group, and 13 in the control group. The mean duration of the surgery in the hemodilution group was longer. The number of levels submitted to surgery ranged from 7 to 16 in the hemodilution group, and from 4 to 13 in the control group. Osteotomy, predominantly of the posterior kind, was performed in 20 patients. There was more intraoperative bleeding in the control group. All patients were stable during the procedures. Only 6 participants needed homologous blood transfusion, mostly from the control group (p > 0.05). Conclusion There was no significant difference between the two groups regarding the need for blood transfusion and intraoperative bleeding. The severity of the deformity was the main determinant for homologous blood transfusion.
Resumo Objetivo Comparar de modo prospectivo os parâmetros clínicos e laboratoriais dos pacientes submetidos a hemodiluição normovolêmica aguda associada ao ácido tranexâmico com um grupo de controle que recebeu apenas ácido tranexâmico, durante cirurgia de correção de deformidades da coluna, e avaliar a influência da técnica de hemodiluição no sangramento perioperatório e a necessidade de transfusão de sangue homólogo. Materiais e Métodos Estudo prospectivo comparativo, com pacientes entre 12 e 65 anos submetidos a cirurgia para correção de deformidades da coluna vertebral, com a técnica de hemodiluição normovolêmica aguda associada ao ácido tranexâmico, versus grupo de controle com ácido tranexâmico isolado na dose de 15 mg/kg. Exames laboratoriais foram feitos e analisados em três momentos de avaliação diferentes. Resultados Participaram deste estudo 30 pacientes: 17 no grupo de hemodiluição e 13 no grupo de controle. O tempo médio de cirurgia foi maior para o grupo de hemodiluição. O número de níveis operados variou entre 7 e 16 no grupo de hemodiluição, e entre 4 e 13 no grupo de controle. Fez-se osteotomia, predominantemente posterior, em 20 pacientes. O valor médio de sangramento intraoperatório foi maior no grupo de controle. Os parâmetros clínicos se mantiveram estáveis durante todos os procedimentos. Apenas 6 pacientes necessitaram de transfusão sanguínea homóloga, a maioria dos quais pertencia ao grupo de controle (p > 0,05). Conclusão Não houve diferença significativa entre os dois grupos quanto à necessidade de transfusão e sangramento intraoperatório. A gravidade da deformidade foi o principal fator determinante da transfusão.
Subject(s)
Humans , Male , Female , Child , Adolescent , Adult , Middle Aged , Scoliosis , Spine , Blood Transfusion, Autologous , Hemodilution/methods , HemorrhageABSTRACT
Introduction: Hemodilution during cardiopulmonarybypass is an acceptable method to avoid the complications ofcontinuous flow at the microcirculatory level. Hemodilutionalanemia during cardiopulmonary bypass can lead to inadequateoxygen delivery and, which may result in ischemic organinjury to all the organs especially to the brain, kidney, lungs andliver. Study aimed to investigate the effectiveness of a novelformula for calculating priming volume (PV) and requiredpacked cell (PC) volume to maintain optimal hematocrit levelduring cardiopulmonary bypass.Material and methods: This Prospective interventional studywas done on 150 patients who underwent open-heart surgeriesin our Institute from January 2018 to December 2018. GroupA-75 patients: perfusionist’s old protocol for calculatingpriming volume and required packed cell volume calculationand the nadir hematocrit (Hct) during CPB and postoperativeoutcome monitored. Group B- 75 patients: customizednovel formula was applied for calculating PV and requiredPC volume and the nadir Hct during CPB and postoperativeoutcome monitored and both the groups compared.Results: In our study results showed that maintaining optimalHct of 25% (>20%) in adult and 30% (>25%) by using ournovel customized formula for calculating prime volume andrequired packed cell volume was significantly improvedthe nadir Hct from 19.16% to 21.8% as well as average Hctvalues from 19.7% to 23.4%. Complications of Hemodilutionwere significantly reduced in the study Group B. Mortalitywas reduced to 2.7% from 5.3%. Respiratory complicationlike reintubation rate and nonfatal noncardiogenic pulmonaryedema rates reduced from 34.7% to 17%. Coagulopathy withpostoperative blood products requirement reduced from 20%to 7%.Conclusion: Our Study showed that application of this novelformula is very useful and easy for both the perfusionists andthe surgeons in maintaining optimal Hct during CPB therebyimproving the postoperative results following open heartsurgeries.
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BACKGROUND: We investigated the effect of irrigation fluid on coagulation according to the hemodilution level using rotational thromboelastometry (ROTEM). METHODS: Venous blood was taken from 12 healthy volunteers and divided into four specimen tubes that were diluted to various levels (0%, 10%, 20%, and 40%) using an irrigation fluid composed of 2.7% sorbitol and 0.54% mannitol. RESULTS: Significant prolongation of clotting time was observed in the 40% diluted sample using both INTEM (P = 0.009) and EXTEM (P = 0.001) assays. However, the clot formation time was prolonged significantly in the 10%, 20%, and 40% diluted samples using both INTEM (P < 0.001) and EXTEM (P = 0.002, P < 0.001, and P < 0.001, respectively) assays. A significant decrease of α-angle of INTEM and EXTEM were observed in the 10% (P < 0.001), 20% (P < 0.001 and P = 0.001, respectively), and 40% (P < 0.001) groups compared with the 0% dilution group. The maximum clot firmness (MCF) of INTEM decreased significantly in the 20% (P < 0.001) and 40% (P < 0.001) diluted samples. In the MCF of EXTEM and FIBTEM assays, 10% (P = 0.009 and P = 0.015, respectively), 20% (P = 0.001), and 40% (P < 0.001) samples showed a significant decrease compared with the 0% sample. Nevertheless, most of the ROTEM values were within the reference range, except the 40% sample. CONCLUSIONS: Blood became hypocoagulable when it was diluted in vitro with a fluid composed of 2.7% sorbitol and 0.54% mannitol.
Subject(s)
Blood Coagulation , Healthy Volunteers , Hemodilution , In Vitro Techniques , Mannitol , Reference Values , Sorbitol , ThrombelastographyABSTRACT
Aim To assess the hemodilution during mitral valve surgery performed using St Thomas cardioplegia versus Del Nido cardioplegia. We also compared the volume of cardioplegia required, cross clamp time and cardiopulmonary bypass (CPB) time in each group. Methods and Materials Patients admitted between the period of January 2015 to June 2018 for mitral valve disease were included in this retrospective study. Patients were divided into two groups each comprising of 50 patients according to type of cardioplegia received during surgery. Results The hemodilution was much lesser in the patients who underwent mitral valve surgery using St Thomas cardioplegia (Haematocrit 26.3 ± 2.5%) as compared to those patients underwent the same surgery using del Nido Cardioplegia (Haematocrit 24.8 ± 2.2%). The volume of cardioplegia, cross clamp time and cardiopulmonary bypass time was less with del Nido cardioplegia as compared to St. Thomas cardioplegia (922.6 ± 95.4 vs 1854 ± 228.1 ml; 65.5 ± 8.2 vs 71.52 ± 8.8 minutes and 99.3 ± 13.1 vs 110.6 ± 14.6 minutes respectively). Conclusion The use of St Thomas Cardioplegia in patients during mitral valve replacement surgery has less hemodilution on CPB as compared to del Nido cardioplegia. But the patients who received del Nido cardioplegia has less requirement of number and volume of cardioplegia required during surgery with shorter cross clamp and CPB time
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AIMS AND OBJECTIVES : To study the effect of retrograde autologous priming techniques on transfusion requirements and outcome in CABG patients. 1. The effect on peri-operative transfusion requirements. 2. The effect on post-operative morbidity. 3. The effect on duration of post operative stay MATERIALS AND METHODS : We analysed the patient details retrospectively using the charts as well as our clinical clinical workstation. Categorical data were expressed as frequency and percentage. Categorical data were expressed as frequency and percentage. Continuous variable expressed as mean standard deviation. Significant differences between proportions determined by Chi-squared analysis or Fischer‘s exact test. All analysis were carried out using Statistical Package for Social Service version 16(SPSS Inc.,Chicago, IL, USA). Probablity values p<0.05 were considered significant. RESULTS: We had a total of 200 patients in our series from 2014-15. Coronary artery disease is more common in males 83% of our study group. Commonly seen in Diabetics(60%), hypertensives(62%) and smokers(30%), their respective percentages in the study population. Analysing Retrograde autologus priming as a blood conservation modality we were able to derive at a reduction in hemodilution, transfusion rates, creatnine and lactate levels, period of stay but were not able to exhibit statistical significance. The factors like intra operative hemodilution(p=0.039) and transfusion(p=0.050). Post operative creatnine levels(p=0.026) and Stay in the ICU(p=0.014) were significant. CONCLUSION: We were able to establish Retrograde Autologus Priming as one of the blood conservation modalities. As in other literature, our study also suggests that Retrograde Autologus Priming of cardiopulmonary bypass circuit as an effective blood conservation modality. There is a significant reduction in the total transfusion rates of patients in the Retrograde Autologus Priming group in the overall study. Though only the intra op transfusion rates and post operative critical care stay were deemed statistically significant, in this retrograde study, It is promising to note and could get more gratifying results if there could be a prospective study with strict transfusion triggers
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Background: Cardiovascular disease is one of the most common causes of mortality in developed countries, as well as in the whole world. In this regard, autologous transfusion is a topic that can be useful and valuable, especially in complex surgery such as heart surgery and organ transplantation. One of its variants is Acute Normovolomic Hemodilution (ANH). Therefore, the aim of this study was to compare the effect of ANH on the amount of bleeding in the first 48hours after coronary artery bypass grafting.Methods: In this clinical trial, 100 patients were selected from all heart patients referred to Imam Khomeini Hospital in Ardebil for CABG surgery in the years 2016-17. They were selected by simple random sampling as a statistical sample and They were divided into intervention (50 ANH recipients’ people) and control groups (50 without ANH people).Results: Based on the findings, in the ANH recipients’ group, the mean of bleeding volume was 59.1±7.3ml in the first day and 55.6±4.2ml in the control group and the difference between the two groups was not significant on the first day. The mean of bleeding volume on the second day was 46.1±2.8ml in the ANH group and 42.7±2.9ml in the control group. Although it was somewhat higher, it was not statistically significant. Of all samples 45% were female and 55% were male. The most common type of blood group was 33 (33%) in the blood group O. The highest age group (61%) was over the 60 years old. The pump time varied with an average of 122.2±21.5minutes. The lowest value was PT 11 and the highest was 15 with an average of 13.02±0.9seconds. The mean of PTT was 32.5±2.6seconds and the mean INR was 1.1±1.0. The average plt was 251170±64124. The mean ACT was 596 / 6±183/7seconds.Conclusions: The results showed that in the mean of bleeding volume between the intervention and control groups (p = 0.41), bleeding volume by age (p = 0.3), bleeding volume by gender (p =0.54) and bleeding volume by blood group (p=0.48) was not significant difference. Based on these results, it is suggested that more studies be done on the more number of samples.
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Objective To observe the clinical efficacy and safety of acute hypervolemic hemodilution (AHH) in combination with controlled hypotension (CH)and autologous blood transfusion (ABT)on spinal surgery. Methods For this study,we enrolled 50 patients undergoing spinal surgery and randomly divided them into two groups.The experimental group received AHH in combination with CH and ABT,while the control group received none of the above treatments.We compared the parameters such as hemodynamics,blood routine and coagulation, the amount of intraoperative bleeding,autologous and allogeneic blood transfusion volume,and regional cerebral oxygen saturation (rSO2)between the two groups.Results In the experimental group CVP increased,while invasive artery blood pressure, HCT, Hb, PLT and the amount of allogeneic blood transfusion decreased significantly compared with those of the control group (P<0.05).As for the mean intraoperative blood loss, APTT,PT,TT,FIB and rSO2,there were no significant differences between the two groups (P>0.05). Conclusion AHH in combination with CH and ABT can reduce the amount of allogeneic blood transfusion and has no adverse effect on hemodynamics,blood coagulation or cerebral oxygenation in spinal surgery patients.It is a safe and effective blood protection procedure during spinal surgery.
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Increasingly, autologous blood transfusion has been arousing concern owing to awareness of adverse effects of allogenic blood transfusion, blood shortage and patients, having religious or personal issues. With the development of medicine, Cell Salvage and Acute normovolemic hemodilution (ANH) has been proposed as an alternative to allogenic blood transfusion. This review looked at the use of ANH and cell salvage and evaluated the benefits and usefulness based on the strengths and indications. Although not consistent with all cases of ANH, there were benefits in the amount of hemorrhage and transfusion, and no supplementary plasma or platelet transfusion was needed after surgery when employing ANH. But, it showed a cutoff value only for massive bleeding surgery (at least 500 mL). In the case of cell salvage, the amount of blood transfusion was reduced in most cases and platelet or plasma transfusion was not required in most cases. When the Leukoreduction filter (LDF) was utilized, it showed the effect of removing bacterial infection or tumor cells. Nonetheless, the effectiveness and benefits for patients in certain condition of cell salvage and ANH is ambiguous with discrepancies among studies or patients. Therefore, the aim of this study is to provide clinical knowledge relative to the procedure, measure the efficacy and usefulness of peri-operative blood management mentioned above and discuss the forthcoming prospects and challenges.