Standards and Best Practice for Acute Normovolemic Hemodilution: Evidence-based Consensus Recommendations.

OBJECTIVE: To develop a standardized approach to the implementation and performance of acute normovolemic hemodilution (ANH) in order to reduce the incidence of bleeding and allogeneic blood transfusion in high-risk surgical bleeding-related cardiac surgery with cardiopulmonary bypass (CPB). DESIGN: A 2-round modified RAND-Delphi consensus process. PARTICIPANTS: Seven physicians from multiple geographic locations and clinical disciplines including anesthesiology and cardiac surgery and 1 cardiac surgery perfusionist participated in the survey. One registered nurse, specializing in Patient Blood Management, participated in the discussion but did not participate in the survey. METHODS: A modified RAND-Delphi method was utilized that integrated evidence review with a face-to-face expert multidisciplinary panel meeting, followed by repeated scoring using a 9-point Likert scale. Consensus was determined as a result from the second round survey, as follows: median rating of 1-3: ANH acceptable; median rating of 7-9: ANH not acceptable; median rating of 4-6: use clinical judgment. RESULTS: Evidentiary review identified 18 key peer-reviewed manuscripts for discussion. Through the consensus-building process, 39 statements including 26 contraindications to ANH and 10 CPB patient variables were assessed. In total, 22 statements were accepted or modified for the second scoring round. CONCLUSIONS: Consensus was reached on 6 conditions in which ANH would or would not be acceptable, showing that development of a standardized approach for the use of ANH in high-risk surgical bleeding and allogeneic blood transfusion is clearly possible. The recommendations developed by this expert panel may help guide the management and inclusion of ANH as an evidence and consensus-based blood conservation modality.

Effects of resuscitation fluid on neurologic physiology after cerebral trauma and hemorrhage.

BACKGROUND: The current standard of care for fluid resuscitation of hemorrhagic hypotensive patients involves the use of crystalloid solutions. Traumatic brain injury (TBI) is often associated with hemorrhage and hypotension, which can contribute significantly to morbidity and mortality. Guidelines for the choice of fluid resuscitation and the use of red blood cell transfusions are not yet clear in the context of brain injury. METHODS: Various fluid resuscitation strategies were evaluated in Sprague-Dawley rats using fresh blood, normal saline, hypertonic saline, and albumin fluid resuscitation protocols. Mean arterial blood pressure (MAP) and cerebral oximetry were assessed in hemorrhaged groups and the mean population spike amplitudes (PSA) from the hippocampus were examined in fluid percussion injured (FPI) animals subject to hemorrhage and fluid resuscitation. RESULTS: MAP in control animals, hemorrhage and hemorrhage + albumin treated groups was 82.4 +/- 1.5 mm Hg, 55.7 +/- 1.5 mm Hg, and 97.0 +/- 3.4 mm Hg, respectively. Arterial PaO2 was higher in albumin-treated animals relative to other fluid alternatives. Regional tissue oxygen tension (PbrO2) levels in hemorrhaged animals reached significantly higher levels in albumin treated group compared with in normal saline and hypertonic saline (p < 0.001, p = 0.034, respectively). After FPI+hemorrhage, PSA values in albumin- resuscitated animals were significantly higher than in normal saline-resuscitated animals (p = 0.012). CONCLUSIONS: The results of normal saline resuscitation, relative to other fluid alternatives, suggest that a re-evaluation of current treatment strategies in hemorrhagic hypotensive TBI patients is warranted. Albumin demonstrated the greatest beneficial effects on neurophysiology endpoints over crystalloid alternatives. These data suggests that albumin resuscitation may play an important role in the treatment of hemorrhagic hypotension and TBI.