Abstract
Background: Deliberate hypotension under spinal or epidural anesthesia is a readily available and effective method to reduce intraoperative blood loss in total hip arthroplasty. However, induced hypotension has been shown to alter the physiologic handling of crystalloid solutions, with blood volume increasing in proportion to the drop in blood pressure. This study aims to investigate the effect of hemodilution secondary to hypotensive anesthesia and volume loading on postoperative hemoglobin levels. Methods: 211 non-anemic adult patients who underwent primary total hip arthroplasty utilizing a minimal invasive posterior approach with hypotensive spinal-epidural anesthesia were evaluated retrospectively. The effect of fluid loading under hypotensive anesthesia was investigated by calculating the blood loss that corresponds to patients’ preoperative and postoperative hemoglobin levels, as well as calculating the hemoglobin levels expected for known volumes of blood loss. Results: There was a large discrepancy between the calculated blood loss (1358 mL) and the actual measured blood loss (212 mL). Patients received an average of 4488 (SD 1209) mL of intravenous fluid within 24 hours of surgery. There was also a large difference between the calculated hemoglobin level based on the measured blood loss (13.6 g/dL) and the actual measured mean hemoglobin (10.8 g/dL). Conclusion: Blood volume expansion and hemodilution with hypotensive epidural anesthesia leads to decreased hemoglobin levels in the early postoperative period and likely impacts on transfusion requirements. Hypotensive anesthesia might have a detrimental effect on transfusion requirements in procedures with relatively low blood loss.
Highlights
Hypotensive epidural anesthesia is a readily available and effective method to reduce intraoperative blood loss in total hip arthroplasty (THA) [1]
All hip arthroplasty procedures were performed by the principle investigator utilizing a minimal invasive posterior approach with hypotensive spinal-epidural anesthesia
The patients in this study were preoperatively non-anemic with an average preoperative Hb of 14.5 g/dl in males and 13.5 g/dl in females and similar mean American Society of Anesthesiologist (ASA) score of 2
Summary
Hypotensive epidural anesthesia is a readily available and effective method to reduce intraoperative blood loss in total hip arthroplasty (THA) [1]. Continuous intravenous infusion of a low-dose epinephrine solution is used to stabilize heart rate, CVP and cardiac output during hypotension This results in arterial hypotension with preservation of central venous pressure, heart rate, stroke volume, cardiac output, and an augmentation of blood flow to the lower extremity [2]. The technique does not appear to adversely affect cardiac, renal, or cerebral function and is used safely in patients with hypertension, ischemic heart disease, and in the elderly It has been associated with reduced intraoperative blood loss, and with fewer perioperative blood transfusions [5,6], a lower rate of deep vein thrombosis [7,8], and a low perioperative mortality rate [9]. This study aims to investigate the effect of hemodilution secondary to hypotensive anesthesia and volume loading on postoperative hemoglobin levels
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