Acute Hypervolemic Hemodilution Group Research Articles

Influences of acute hypervolemic hemodilution on serum levels of S-100β protein, NSE and POCD in elderly patients with spinal surgery

To explore the influences of acute hypervolemic hemodilution(AHH) on serum levels of S-100β protein, neuron specific enolase(NSE) and postoperative cognitive dysfunction POCD in elderly patients with spinal surgery. A total of 80 cases elderly patients requiring elective spinal operation were divided into AHH group and C group according to random digits table, 40 cases in each group, with ASA grade I-II. The patients in AHH group were infused 6% hydroxyethyl starch 130/0.4 at a rate of 20 ml/min after anesthesia induction, and blood volume increased by about 20%, the patients in C group were not received AHH, anesthesia and surgical methods were the same as those in AHH group. Intraoperative blood volume, allogeneic blood transfusion and urine volume were recorded. Mean arterial pressure(MAP), heart rate(HR), central venous pressure(CVP) at preoperative 1 d, 1 h after the start of surgery, end of operation, 12 h after surgery were observed. Arterial blood oxygen content (CaO₂), venous blood oxygen content (CjvO₂), arteriovenous oxygen content difference (Da-jvO₂), and cerebral oxygen uptake(CERO₂) were measured at 1 d before surgery, 15 min after surgery, 45 min after surgery, end of surgery. Mini-mental state examination(MMSE) score and serum levels of S-100β protein, NSE were measured at 1 d before surgery, 1, 3, 7 d after surgery. POCD rates of two groups were recorded. Intraoperative blood loss and allogeneic blood transfusion in AHH group was significantly lower than those in C group(P<0.05), and the urine volume was significantly higher than that in C group (P<0.05). Compared with preoperative 1 day, MAP was decreased and CVP was increased at end of surgery in AHH group, compared with C group at the same time, MAP was lower and CVP was higher in AHH group, but both were in normal range. Compared with preoperative 1 day and C group, the levels of Da-jvO₂ and CERO₂ in AHH group was decreased at 15, 45 min after the start of the operation and end of surgery(P<0.05). Compared with preoperative 1 day, MMSE scores of two groups at 1 day after surgery was decreased (P<0.05), the levels of S-100β protein and NSE were increased(P<0.05), and restored at 3, 7 days after surgery. There was statistical difference in MMSE scores, the levels of S-100β protein, NSE at 1 day after surgery between two groups (P<0.05). There was no statistical difference in POCD rate between two groups(P>0.05). AHH can significantly reduce intraoperative blood loss and blood transfusion in elderly patients with spinal surgery, and decrease the levels of S-100β protein and NSE, does not increase the risk of the occurrence of POCD.

Pharmacokinetics and pharmacodynamics of cisatracurium in patients undergoing surgery with two hemodilution methods

ObjectiveTo investigate the pharmacokinetics and pharmacodynamics of cisatracurium in patients undergoing surgery under acute normovolemic hemodilution (ANH) and acute hypervolemic hemodilution (AHH). MethodsNinety patients with orthopedic surgery were divided into ANH, AHH and control groups, which received hemodilution by hydroxyethyl starch 130/0.4 transfusion, Voluven transfusion and regular transfusion and infusion during surgery, respectively. Each group was divided into 3 sub-groups, administrated with cisatracurium at dosage of 0.1, 0.2 and 0.3mg/kg respectively. The changes in plasma protein, pH and electrolytes from the hemodilution beginning to surgery finish were monitored. Before and after cisatracurium administration, the phamocodynamic indicators of muscle relaxant were observed, and the plasma drug concentration was measured. ResultsAfter hemodilution or regular transfusion, all three groups experienced a distinct drop in total plasma protein, albumin and pH. Compared with control group, the plasma concentrations of both K+ and Ca2+ in ANH and AHH groups significantly dropped (P<0.05), and those in each group after administration of cisatracurium also dropped, compared with before (P<0.05). After administration with cisatracurium, the onset time of muscle relaxation in AHH group was extended notably, compared with AHH and control groups (P<0.05), with no distinct difference of residual pharmacodynamics parameters (P>0.05). In the same hemodilution or regular infusion, with increase of drug dosage, the onset time of muscle relaxation was shortened, and the period of no response to train-of-four stimulation, muscle relaxation blockade duration and action time of muscle relaxation blockade in body were extended (P<0.05). ConclusionWhen using cisatracurium under AHH, the dosage should be increased appropriately, while it need not be adjusted under ANH.

Effect of acute hypervolemic hemodilution of 6% hydroxyethyl starch 130/0.4 on the EC50 of propofol at two clinical endpoints in patients.

Preoperative acute hypervolemic hemodilution (AHHD) is a technique used in anesthesia to reduce the number of blood cells lost during intraoperative bleeding. The aim of the present study was to evaluate the effect of the hypervolemic hemodilution of 6% hydroxyethyl starch 130/0.4 on the EC50 of propofol at two clinical endpoints. A total of 20 patients undergoing AHHD following epidural anesthesia were studied, and 20 patients who did not receive hemodilution were used as a control group. All patients were American Society of Anesthesiologists grade I, aged 20–40 years and undergoing hip arthroplasty surgery. In the AHHD group, 10 ml/kg lactated Ringer's solution was infused over 20 min at the same time as the epidural test dose. The infusion was followed by the infusion of 6% hydroxyethyl starch 130/0.4 over 30 min. Patients in the control group received 10 ml/kg Ringer's solution over 50 min. Propofol was then delivered by a Diprifusor target-controlled infusion. The predicted blood and effect-site propofol concentrations were recorded at loss of consciousness (LOC) and return of consciousness (ROC). Probit analysis was used to estimate the values for predicted blood and effect-site concentrations at the two clinical endpoints. The results showed that the potency of propofol was decreased during AHHD. Compared with the controls, the predicted blood and effect-site concentrations of propofol at LOC were higher in patients of the hemodilution group, resulting in higher EC50 values (P=0.001 and 0.025, respectively). At ROC, the effect-site EC50 was 2.9 µg/ml [95% confidence interval (CI), 2.8–3.0] in hemodilution patients and 2.5 µg/ml (95% CI, 2.2–2.6) in control patients (P=0.001). With AHHD, the LOC time was significantly longer and the propofol dose was higher, while ROC times were comparable. In conclusion, AHHD increases the requirement for propofol at LOC and prolongs LOC time. Patients with AHHD recovered consciousness at higher effect-site concentrations of propofol. Thus, the induction dose of propofol should be increased during AHHD.

Effects of different durations of severe acute hypervolemic hemodilution on acute lung injury in rabbits

Objective To evaluate the effects of different durations of severe acute hypervolemic hemodilution (AHH) on acute lung injury in rabbits. Methods Thirty-six healthy adult rabbits of both sexes, weighing 2.7-3.1 kg, were randomly divided into 2 groups (n=18 each) using a random number table: control group (C group) and AHH group.AHH was performed with 6% hydroxyethyl starch 130/0.4 until the target hematocrit of 20% was achieved in group AHH.Immediately before AHH (T0), and at 1, 2 and 4 h after AHH (T1-3), blood samples were taken from the right femoral artery for blood gas analysis.The oxygenation index was calculated.The occurrence of acute lung injury (oxygenation index ≤ 300 mmHg) was recorded.After blood samples were collected at T1-3, 6 rabbits in each group were sacrificed, and lungs were removed for determination of wet/dry lung weight ratio (W/D ratio) and aquaporin-1 (AQP-1) expression (by immuno-histochemistry). Results In group AHH, 1 rabbit developed acute lung injury at 1-2 h after AHH, and 4 rabbits developed acute lung injury at 2-4 h after AHH.Compared with group C, W/D ratio was significantly increased at T1-3, and the expression of AQP-1 was down-regulated at T2, 3 in group AHH (P<0.05 or 0.01). Conclusion Severe AHH performed with 6% hydroxyethyl starch 130/0.4 with the target hematocrit reduced to 20% and the duration > 1 h induces acute lung injury in rabbits. Key words: Hemodilution; Respiratory distress syndrome, adult

Effect of acute hypervolemic hemodilution on myocardial damage in severely burned rabbits

Objective To evaluate the effect of acute hypervolemic hemodilution(AHH)on myocardial damage in severely burned rabbits. Methods Eighteen healthy adult rabbits, weighing 2.0-2.5 kg, were randomly divided into 3 groups(n=6 each)using a random number table: control group(group C), burn group(B group)and AHH group.Rabbits were subjected to 3rd degree burn covering 40% of the total body surface area.After the model was established, 6% hydroxyethyl starch 130/0.4 was infused intravenously, and the target Hct was 25% in AHH group.Before AHH(T0)and at 2, 4 and 8 h after AHH(T1-3), left ventricular systolic pressure(LVSP), left ventricular end-diastolic pressure(LVEDP), + dp/dtmax and -dp/dtmax were recorded, and blood samples from femoral veins were taken to determine the concentration of serum cardiac troponin I(cTnI)by ELISA.The rabbits were sacrificed at T3, and myocardial specimens were removed for microscopic examination of pathological changes with light microscope. Results Compared with group C, the serum cTnI concentration and LVEDP were significantly increased, LVSP and + dp/dt max were decreased at T1-3 in B and AHH groups, and -dp/dtmax at T1-3 in group B and -dp/dtmax at T3 in group AHH were decreased.Compared with group B, LVSP, + dp/dtmax and -dp/dtmaxwere significantly increased at T1-3, and no significant change was found in serum cTnI concentration and LVEDP in group AHH.There was no significant difference in the pathological changes between group B and group AHH. Conclusion AHH can not aggravate the early myocardial damage in severely burned rabbits. Key words: Hemodilution; Burns; Myocardial reperfusion injury

Responsiveness of stroke volume variation and central venous pressure during acute normovolemic and hypervolemic hemodilution.

Stroke volume variation (SVV) is a robust indicator of fluid responsiveness during volume change. We compared the sensibility of SVV by Vigileo/Flotrac to central venous pressure (CVP) when volume changes in patients undergoing intraoperative acute normovolemic hemodilution (ANH) and acute hypervolemic hemodilution (AHH). Forty patients were randomly divided into an ANH group (n = 20) and an AHH group (n = 20). All patients received general anesthesia and were mechanically ventilated. Data were collected from 7 different time-points in the ANH group: baseline, after withdrawal of 5%, 10%, and 15% of the estimated blood volume (EBV) and after replacement with an equal volume of 6% hydroxyethyl starch 130/0.4 (HES) in 5% EBV increments to baseline. There were four time points in the AHH group: baseline, after 5%, 10%, and 15% expansion of the EBV with 6% HES. At each time-point, CVP, SVV and other hemodynamic parameters measurements were obtained. After removal of 10% and 15% EBV, SVV significantly increased from 10.9 ± 3.0 to 14.1 ± 3.4 and 10.9 ± 3.0 to 16.0 ± 3.3 (P < 0.01), and returned to a final value of 10.6 ± 3.4 after volume replacement. The CVP value was unchanged after removal and replacement of 15% of the EBV. There were no significant changes in SVV after 5%, 10% whereas there was a significant reduction after 15% (8.2 ± 1.7) expansion of the EBV compared with baseline (9.9 ± 1.8) (P = 0.033). However, there was a significant increase in CVP after 10% (10.3 ± 2.4), 15% (11.3 ± 2.2) expansion of the EBV compared with baseline (8.2 ± 2.7) (P < 0.01). SVV is a more sensitive parameter for volume than CVP during hypovolemia, on the contrary CVP is more sensitive than SVV during hypervolemia.

Blood-saving effect of acute hypervolemic hemodilution with 6％ hydroxyethyl starch 130/0.4 in preschool children

Objective To evaluate the blood-saving effect of acute hypervolemic hemodilution (AHH) with 6％ hydroxyethyl starch 130/0.4 (HES 130/0.4) in preschool children.Methods Forty ASA Ⅰ patients,aged 3-6 yr,weighing 11.5-22.5 kg,with body height of 78-120 cm,scheduled for orthopedic or general surgeries,were divided into 2 groups by drawing lots:group AHH (n =20) and group control (n =20).6％HES 130/0.4 10 ml/kg was infused over 30 min at a rate of 0.3 ml·kg-1 · min-1 through the internal jugular vein before surgery in group AHH.The fluid balance,blood loss,urine output and blood transfusion during operation were recorded.The blood routine,liver and kidney function and coagulation function (prothrombin time (PT),activated partial thromboplastin time (APTT),fibrinogen (Fib)) were measured before AHH (T0) and at 0,4 and 24 h after AHH (T1-3).Hypokalemia,hypocalcemia and prolongation of PT and APTT during surgery,and pulmonary edema,heart failure and abnormal bleeding from the site in the wound during the perioperative period were recorded.Results The two groups were comparable with regard to the volume of multiple electrolyte solution consumed,blood loss,parameters of liver and kidney function,platelet count and incidences of hypokalemia and hypocalcemia (P ＞ 0.05).The urine output was significantly increased,Hct at T1 and Fib at T1,2 were significantly decreased,PT and APTT were prolonged,and the percentage of patients without allogeneic blood transfusion and incidences of prolongation of PT and APTT were significantly increased in group AHH as compared with group C (P ＜ 0.05).No pulmonary edema,heart failure and abnormal bleeding were found during the perioperative period.Conclusion AHH with 6％ HES 130/0.4 10 ml/kg provides better blood-saving effect in preschool children,has little effect on the internal environment,but prolongs the coagulation time and exerts effect on coagulation function to some extent. Key words: Hetastarch; Child, preschool; Hemodilution

Influence of acute hypervolemic hemodilution on pharmacodynamics of cisatracurium in patients undergoing general anesthesia

Objective To investigate the influence of acute hypervolemic hemodilution (AHH) on pharmacodaynamics of cisatracurium in patients undergoing general anesthesia. Methods Sixty ASA Ⅰ or Ⅱ patients aged 18-60 yr scheduled for major abdominal surgery under general anesthesia were randomly allocated into 2 groups (n = 30 each): control group and AHH group. Each group was further divided into 3 subgroups according to the initial dose of cisatracurium (30, 40, 50 μg/kg) . The radial artery and right internal jugular vein were cannulated. BP, HR, CVP, SpO_2, P_(ET) CO_2 and body temperature were continuously monitored. The response of left adductor pollicis muscle to TOF stimulation of ulna nerve was monitored using TOF- Watch~R SX (Organon). Both groups received 10 ml/kg multiple electrolyte solution (plasma-Lyte A) during induction of anesthesia. In group AHH 15 ml/kg 6% hydroxyethyl starch (HES) 130/0.4 solution was infused via internal jugular vein over 30-40 min in addition to plasma-Lyte A. Five minutes after completion of plasma-Lyte A or HES, cisatracurium 30, 40 or SO fig/kg was injected iv in the respective subgroups. After the maximal T_1 block was achieved, the second dose was given to reach a total dose of 100 μg/kg. The onset time, duration of clinical action, total duration of action and recovery index were recorded. The doses for 50% , 90% and 95% T_1 depression (ED_(50), ED_(90), ED_(95)) were calculated by Probit method. Results The ED_(50), ED_(90), ED_(95) of cisatracurium were significantly higher in AHH group than in control group. The onset time of cisatracurium was significantly longer but clinical and total duration of action was significantly shorter in AHH group than in control group. There was no significant difference in recovery index between the two groups. Conclusion AHH can decrease the potency of cisatracurium. Key words: Atracurium; Hemoodilution; Neruomuscular blockade

Effects of acute hypervolemic hemodilution with hydroxyethyl starch 130/0.4 on the lung in a rabbit model of sepsis

To investigate the effects of acute hypervolemic hemodilution (AHH) with hydroxyethyl starch (HES) 130/0.4 on the lung in a rabbit model of sepsis and their possible mechanism. Thirty healthy New Zealand rabbits were randomly divided into three groups (n=10 each): group sham operation (C), group sepsis model (E) and group AHH. Sepsis model was reproduced with modified colon ascendens stent peritonitis (CASP). In group C laparotomy was done but without puncturing the colon. At 4 hours after CASP, AHH was carried out intravenous infusion of 6% HES 130/0.4 20 ml/kg at 20 ml/min. Lactated Ringer solution was infused at 10 ml kg (-1) h (-1) in all three groups during the experiment. The animals breathed spontaneously during the experiment. A catheter was introduced into the right carotid artery for blood sampling, and it was connected to a pressure transducer for continuous mean arterial pressure (MAP) and heart rate (HR) monitoring. At 4 hours and 8 hours after CASP, a median abdominal incision was made and photographic documentation of abdominal situs was made. At the same time arterial blood samples were drawn at 4 hours and 8 hours after CASP for blood gas analysis and determination of hemoglobin (Hb) and hematocrit (Hct). The plasma component was separated and tumor necrosis factor-alpha (TNF-alpha) was measured. Respiratory rate and urinary output were record. The rabbits were sacrificed at 8 hours after CASP. The right lungs were immediately removed for determination of total protein concentration in broncho-alveolar lavage fluid (BALF). The wet/dry (W/D) lung weight rate were calculated. The sections of lung were stained with hematoxylin and eosin for light microscopic examination and the injury score was recorded. (1)MAP declined gradually and HR tended to accelerate during the course of the experiment in group E, but no significant differences were found in both group C and group AHH. (2)After AHH, the Hb and Hct decreased by 20% in group AHH. In group E, arterial oxygen saturation (SaO(2)), arterial partial pressure of oxygen (PaO(2)), arterial partial pressure of carbon dioxide (PaCO(2)) and pH decreased significantly at 8 hours after CASP compared with group C (all P<0.05). (3)TNF-alpha concentration in plasma was higher in group E and group AHH than in group C at 4 hours after CASP (both P<0.05). At 8 hours TNF-alpha concentration was increased in group E compared with group C (P<0.05), but there was no significant difference between group C and group AHH. (4)In group E, score of morphological changes in lung was significantly increased compared with group AHH (6.9+/-1.4 vs. 11.2+/-1.7, P<0.05). AHH with HES 130/0.4 can protect the lungs from sepsis. Inhibition of proinflammatory cytokines may be involved in the mechanism.

Clinical observation of acute hypervolemic hemodilution in scoliosis surgery on children

To evaluate the clinical efficacy and safety of acute hypervolemic hemodilution (AHH) in posterior spinal fusion surgery in children. 36 children with scoliosis ASA I approximately II, receive of posterior spinal fusion, were randomly divided into 2 equal groups: AHH group, transfused with hydroxyethyl starch 130/0.4 and sodium chloride (Voluven) 12 ml/kg at the speed of 0.3 approximately 0.4 mlxkg(-1)xmin(-1) (for 30 approximately 40 min) through internal jugular vein before operation so as to keep the hemodilution (Hb) status during operation, and control (CNT) group. During operation when the Hb was <80 g/L or the hematocrit was < 25% blood transfusion was conducted to maintain the Hct > 25%. There was no significant difference in intra-operative blood loss between these 2 groups. The Hb one day after operation of the AHH group was (89 +/- 12) g/L, significantly lower than that immediately after operation [(98 +/- 10) g/L, P < 0.05]. The Hb one day after operation of the CNT group was (92 +/- 22) g/L, significantly lower than that immediately after operation [(94 +/- 13) g/L, P < 0.05]. However, there were not significant differences in the Hb values between the AHH and CNT groups (all P > 0.05). Both groups received intra-operative transfusion during operation. The amount of transfused red blood cells and fresh frozen plasma of the AHH group were (18 +/- 4) ml/kg and (3.5 +/- 1.1) ml/kg respectively, both significantly lower than those of the CNT group [(28 +/- 11) and (5.8 +/- 1.8) ml/kg respectively, both P < 0.05]. Able to reduce intra-operative blood transfusion and medical expense, AHH can be used safely and effectively in posterior spine fusion in children.