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ACUTE NORMOVOLEMIC HEMODILUTION Aryeh Shander, MD, FCCM, FCCP Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital.

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Presentation on theme: "ACUTE NORMOVOLEMIC HEMODILUTION Aryeh Shander, MD, FCCM, FCCP Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital."— Presentation transcript:

1 ACUTE NORMOVOLEMIC HEMODILUTION Aryeh Shander, MD, FCCM, FCCP Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital and Medical Center, Englewood, New Jersey Clinical Professor of Anesthesiology, Medicine and Surgery Mount Sinai School of Medicine, New York

2 ANH The technique Formula or other targets Fluid resuscitation, is there a difference? Induced anemia – safe or risk? Anemia, perfusion and organ function ANH and PBM- outcomes

3 ANH As a blood conservation technique it cannot stand alone and must be accompanied by –Treatment of ANEMIA –Cell salvage and possible fractionation –Post operative management of anemia and coagulation

4 ANH – The Debate ANH – controversial ANH – variety of methods ANH – unclear indications ANH – risk not quantified ANH – more work

5 Acute Normovolemic Hemodilution (ANH)

6 ANH

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8 Practical Issues ANH –Key Points: Vascular access - IV or arterial Monitoring GA and/or Regional Fluid replacement

9 ANH indications and concerns Relative Indications Preop normal Hemoglobin levels Anticipated intraop blood loss > ~1000ml Moderate anticipated blood loss in patient refusing allogeneic transfusion Ability to draw blood after anesthetic induction + before commencement of surgical bleeding Concerns –Ability to tolerate blood withdrawal –Recurarization* ( Br J Anaesth. 2006;97(4):482-8 ) –Coagulation –Fluid overload Hobisch-Hagen P et al. BJA;82(4):503-9

10 Outcome Measurement in Blood Conservation (ANH) Reduced blood loss –Statistically significant reduction of blood loss –Clinically significant reduction of blood loss Reduced blood loss and or eliminate patients exposure to allogeneic transfusions Reduced or eliminate transfusions alone Morbidity – perioperative infection, SIRS or MOF Mortality

11 The Effect of Two Levels of Hypotension on Intraoperative Blood Loss During Total Hip Arthroplasty Performed Under Lumber Epidural Anesthesia Shanrrock NE, et al.Anesth Analg Mar;76(3):580-4.

12 Intraoperative – ANH Effectiveness of acute normovolemic hemodilution to minimize allogeneic blood transfusion in major liver resections Liver resection – at least 30% transfusion requirements Prospective, randomized N = 78 ANH to target Hct 24% vs. controls Transfuse at 20% Matot I, et al. Anesthesiology 2002;97:

13 Intraoperative – ANH Matot I. et al. Anesthesiology 2002;97:

14 ANH The technique Formula or other targets Fluid resuscitation, is there a difference? Induced anemia – whats the limit? Anemia, perfusion and organ function ANH and blood conservation - outcomes

15 V=EBV x H i – H f / H av ANH

16 Weiskopf R.B. Anesthesiology 2001;94:439-46

17 ANH The technique Formula or other targets Fluid resuscitation, is there a difference? Induced anemia – whats the limit? Anemia, perfusion and organ function ANH and blood conservation - outcomes

18 Choice of Fluid Crystalloid Normal Saline Physiologic solutions Colloid HA Penta-Starch Solute

19 Normal Saline vs. LR in Gyn Surgery Total n = 24 Scheingraber et al. Anesthesiology 1999

20 Anemia, viscosity and tissue oxygenation OXYGEN TENSION, mm/hg Tsai AG. Biorheology 38 (2000)

21 Acid-Base Changes Caused by 5% Albumin versus 6% Hydroxyl Starch Solution in Patients Undergoing ANH Rehm M, et. Al. Anesthesiology 2000;93: N=20 Gyn surgery ANH to HCT 22% 10 HES and 10 HA in NaCl solution Blood volume well maintained in both groups Metabolic acidosis (SID) with both after ANH

22 ANH The technique Formula or other targets Fluid resuscitation, is there a difference? Induced anemia – safe or risk? Anemia, perfusion and organ function ANH and blood conservation - outcomes

23 VO 2 vs. DO 2 DO 2 ml/m2/min VO 2 Critical point of DO 2 E.C.S.M. van Woerkens A&A 75, 1992

24 Normovolemic Anemia N=33 Weiskopf et.al. JAMA 279, #3 1998

25 Critical Oxygen Delivery in Conscious Humans time DO 2 and VO 2 ml O 2 Kg -1 min -1 N=8 Hb. 4.7+/- 0.2 g/dl Lieberman JA Anesthesiology 2000; 92: * *

26 ANH & Coagulation aPT, INR, aPTT, platelets and fibrinogen No significant change at 500, 1000 ml 1500 ml, aPT and INR increased without increased in nonsurgical bleeding

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29 Acute Severe Isovolemic Anemia Impairs Cognitive Function and Memory in Humans Weiskopf R.B. et.al., Anesthesiology 2000;92: N=9 volunteers - reaction time and calculation were impaired at Hb of 5.0gm/dl but not 7.0gm/dl No PET scan, tests min after anemia induction Impaired vs. protective Oxygen Reverses Deficits of Cong. Function and Memory and Increased Heart Rate Induced by Acute Severe Isovolemic Anemia Weiskopf R.B. et.al. Anesthesiology 2002;96: Acute Isovolemic Anemia Does Not Impair Peripheral or Central Nerve Conduction Weiskopf R.B., et.al. Anesthesiology 2003;99(3): Peripheral conduction but no CNS effect at 5.0gm/dl

30 Cardiovascular Disease

31 Coronary Flow Flow resistance is primarily reduced by reduction of viscosity Coronary flow is markedly increased with ANH - Subendo and Subepicardial, improved oxygen utilization –Increased myocardial O 2 extraction –Active coronary vasodilatation –MVO 2 (myocardial BF X CaO 2 ) remain stable Extraction ratio in severe ANH is UNCHANGED until Hct drops below 12.5% (Hgb 4.5) Jan KM, Am J Physiol 1977;233:H106 Levy PS et al. Am J Physiol 1993;265:H340-9

32 Cardioprotective effects of acute normovolemic hemodilution in patients with severe aortic stenosis undergoing valve replacement N = 40 patients scheduled for elective AVR - randomly assigned to a control group (standard care) or an ANH group (target hematocrit level of 28%) In the ANH group: –Postoperative release of troponin I (1.7 ng/mL) and myocardial fraction of creatine kinase (22 U/L) was significantly lower than in the control group (3.6 ng/mL and 45 [U/L, respectively) –Circulating levels of erythropoietin (EPO) were higher than in control patients (13.6 +/- 4.2 mUI/mL vs /- 2.4 mUI/mL; p < 0.05). Fewer hemodiluted patients presented adverse cardiac events Preoperative ANH further attenuates myocardial injuries ANH-induced cardioprotection: –Optimization of preischemic myocardial oxygen delivery and/or consumption –Postconditioning effects of endogenous EPO Licker M. et al. Transfusion Feb;47(2):341-50

33 Perioperative time course of serum concentrations of total CPK (A), CK-MB (B), and cTnI (C) in the control ( ) and ANH ( ) groups. *p < 0.05, between the two groups; #p < 0.05, compared with baseline Licker M. et al. Transfusion Feb;47(2):341-50

34 ANH & CARDIAC DISEASE

35 Significant Intraoperative Predictors of Transfusion Based on Patients With a Preoperative Estimated Risk of Transfusion 5%a Risk Factors OR CI Multivariate p Value CPB time – No. of bypass grafts (3) – Total crystalloid (2,500 mL) – Total ANH – n 145 observations; 5 were excluded because of missing values for a covariate; Hosmer-Lemeshow statistic for lack of fit of this model has a p value of 0.72, and the c statistic ANH acute normovolemic hemodilution; CI confidence interval; Moskowitz D, Klein J.J, Shander A et.al. Ann Thorac Surg 2004;77:626–34

36 Blood Conservation Englewood Hospital and Medical Center

37 CABG Outcomes PBMP vs Non-PBMP Moskowitz et al Ann Thorac Surg 2010 N=586

38 Outcome of ANH Cost effective –Monk TG, et al. Transfusion 1996;36(6): ANH cost effective vs PAD in rad prostate surgery –Monk TG, et al. A&A 1997;85(5):953-8 ANH replaces PAD –Monk TG, et al. Anesthesiology 1999;(1):24-33 EPO, ANH and PAD – ANH least costly –Goodnough LT, et al. Vox Sang 1999;77(1):11-6 RT of ANH vs PAD TKA – ANH less costly –Goodnough LT, et al. Transfsion 2000;40(9): RT ANH vs PAD in THA – ANH less $$

39 Clinical Studies Meta-analysis of 24 randomized prospective studies of ANH in 1,218 patients ANH reduced likelihood of allogeneic exposure and total units of allogeneic blood transfused Bryson, G. L. et al., Anesth Analg 1998, 86: 9

40 Evaluation of Acute Normovolemic Hemodilution and Autotransfusion in Neurosurgical Patients Undergoing Excision of Intracranial Meningiom Prospective randomized study N = 40 (over 2 years) Group I (Control Group) - Group II (ANH Group) –Surgical blood loss in group I was ± ml vs ml in group II –Mean blood transfused in group I was ± ml vs. 165 ± ml in group II [statistically significant (p<0.05)] ANH up to a target hematocrit of 30% is safe and effective in reducing the need for allogeneic blood Naqash IA. Et al. J Anaesthesiol Clin Pharmacol Jan;27(1):54-8

41 Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy Management N = 130 (July 2005 to May 2009) randomized to ANH or standard management (STDM) –Transfusion rates were similar (ANH = 16.9%, 30 units vs STD = 18.5%, 33 units; P = 0.82) –Morbidity (ANH = 49.2% vs STD = 47%, P = 0.86) –More grade-3 complications in patients undergoing ANH (32% vs 23.1% STD, P = 0.17) –Pancreatic anastomosis complications higher in the ANH group (21.5% vs 7.7%, P = 0.045) ANH did not reduce allogeneic transfusions Restrictive intravenous fluid management during PD may help improve postoperative outcome Fischer M. et al. Ann Surg Dec;252(6):952-8

42 A Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared to Standard Intraoperative Management in Patients Undergoing Major Hepatic Resection N = 130 undergoing major hepatic resection (> or =3 segments) (From April 2004 to March 2007) Randomly assigned to ANH Group or Standard anesthetic management (STD) group –ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD –ANH patients were less often transfused intraoperatively (n = 1, 1.6%) compared with the STD group (n = 7, 10.4%) (P = 0.036) –ANH group had higher postoperative hemoglobin levels (P = 0.01) –ANH group required fewer red cell units overall (28 vs. 47 units) Intraoperative blood loss > or =800 mL: –ANH reduced ABT (18.2% vs. 42.4%, P = 0.045) and FFP (21.1% vs. 48.3%, P = 0.025) ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use Jarnagin WR. Et al. Ann Surg Sep;248(3):360-9

43 Acute normovolemic hemodilution in moderate blood loss surgery: a randomized controlled trial N = 155 patients undergoing elective hip surgery Groups "ANH" (n = 78) or "standard transfusion" (n = 77) Allogeneic transfusion was necessary in 22 (29%) standard transfusion patients and 15 (19%) ANH patients Postoperative complications: –30 (38%) standard transfusion patients compared with 14 (18%) assigned to ANH group (OR, 0.3; 95% CI, ; p = 0.009) The major difference between the groups was the frequency of infective complications ANH reduced postoperative complications Bennett J. et al. Transfusion Jul;46(7):

44 Acute Normovolemic Hemodilution (ANH) Safely reduces allogeneic transfusions and associated complications Cost effective procedure Effective in all surgical procedures – method dependent Dramatically underutilized No standard approach to date

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46 THANK YOU


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