Acute Hypervolemic Hemodilution Research Articles

Effect of acute hypervolemic hemodilution with bicarbonated Ringer’s solution on perioperative S100β and NSE in elderly patients undergoing spine surgery

ABSTRACT To explore the effect of acute hypervolemic hemodilution (AHH) with bicarbonated Ringer’s solution (BRS) on perioperative serum S100β protein (S100β) and neuron-specific enolase (NSE) in elderly patients undergoing spine surgery. Ninety patients with lumbar spondylolisthesis and fracture surgery admitted to our hospital from January 2022 to August 2022 were selected as the study subjects, and they were randomly and equally divided into group H1 (AHH with BRS), group H2 (AHH with lactated Ringer’s solution) and group C (no hemodilution). The serum contents of S100β and NSE of the three groups at different times were evaluated. There were significant differences in the incidence of postoperative cognitive dysfunction (POCD) among the three groups at T1 and T2 (P < 0.05). There were obvious differences in the contents of S100β and NSE among the three groups at T1 and T2 (P < 0.001), with no overt difference in the incidence of perioperative complications among the three groups (P > 0.05). The use of AHH with BRS can effectively reduce the effect on cognitive function in the elderly with spine surgery, which greatly reduces the nervous system injury, and has certain application value in clinic.

High-speed multi-parametric photoacoustic microscopy of cerebral hemodynamic and metabolic responses to acute hemodilution.

The ability of hemodilution to improve vascular circulatory impairment has been demonstrated. However, the effects of acute hemodilution on cerebral hemodynamics and oxygen metabolism have not been assessed at the microscopic level, due to technical limitations. To fill this void, we have developed a new, to the best of our knowledge, photoacoustic microscopy system, which enables high-speed imaging of blood hemoglobin concentration, oxygenation, flow, and oxygen metabolism in vivo. The system performance was examined in both phantoms and the awake mouse brain. This new technique enabled wide-field (4.5 × 3 mm2) multi-parametric imaging of the mouse cortex at 1 frame/min. Narrowing the field of view to 1.5 × 1.5 mm2 allowed dynamic imaging of the cerebral hemodynamic and metabolic responses to acute hypervolemic hemodilution at 6 frames/min. Quantitative analysis of the hemodilution-induced cerebrovascular responses over time showed rapid increases in the vessel diameter (within 50-210 s) and blood flow (50-210 s), as well as decreases in the hemoglobin concentration (10-480 s) and metabolic rate of oxygen (20-480 s) after the acute hemodilution, followed by a gradual recovery to the baseline levels in 1440 s. Providing comprehensive insights into dynamic changes of the cerebrovascular structure and function in vivo, this technique opens new opportunities for mechanistic studies of acute brain diseases or responses to various stimuli.

Acute hypervolemic hemodilution combined with controlled hypotension to minimize blood loss during operations of spine fusion: remifentanil versus magnesium sulfate

BackgroundBlood loss is one of the major problems during operations of spine fusion. Several blood-conservative measures were applied to reduce the incidence of blood loss—among them, acute hypervolemic hemodilution (AHH) and controlled hypotension (CH). This study was designed to detect the effect of combination of AHH with CH induced by remifentanil versus magnesium sulfate on the volume of blood loss, allogeneic blood transfusion, hemodynamics, coagulation, and electrolytes during operations for spine fusion which are risky operations with high incidence of blood loss and blood transfusion. Sixty patients scheduled for posterior fusion of the spine were randomly allocated into three groups of 20 patients each (group I (AHH), group II (AHH combined with remifentanil-based CH), and group III (AHH combined with magnesium sulfate-based CH)). Estimated blood loss and total volume of packed red blood cells (PRBCS) transfused were recorded. Arterial blood pressure (ABP) and heart rate (HR) measures were recorded. Blood samples were obtained for the detection of hemoglobin (Hb) and hematocrit (HCT).ResultsEstimated blood loss, percentage blood loss, and intraoperative RBC transfusion units were significantly high in group I in relation to group II and group III (Table 2). Cardiac output was significantly higher in group I in relation to group II and group III at 10, 15, 30, 45, and 60 min after start of AHH. MBP and HR results were significantly high in group I in comparison with group II and group III at 30, 45, 60, and 90 min and 2 and 3 h after start of study drugs. CVP results were significantly high in group I in relation to group II and group III at 15, 30, 45, 60, and 90 min after start of AHH. PTT was significantly increased in the three study groups in comparison with baseline inside each group after AHH.ConclusionCombination of AHH with CH induced by remifentanil or magnesium sulfate was associated with reduction in estimated blood loss, and total volume of PRBCS transfused. There was no significant difference between hemodynamic parameters with the use of remifentanil or magnesium sulfate except that SBP, DBP, and MBP results were significantly high with magnesium sulfate at 15 min after drug infusion. There was significant increase in PT and PTT after AHH that was not reflected by significant blood oozing from the operative field, or by difficulty in hemostasis.

Preoperative Correction of Anemia to Allow a 3000 ml Blood Loss Without Transfusion in a Jehovah’s Witness Presenting for Explantation of an Infected Hip Joint Prosthesis: A Case Report

A 70-year-old Jehovah's Witness was treated with iron carboxymaltose intravenously, recombinant human erythropoietin alpha subcutaneously, and vitamin B12 and folate orally for 9 weeks to raise hemoglobin (Hb) from 10.8 to 17.0 g/dL before explantation of an infected hip joint prosthesis. The target Hb was calculated from the following formula: Hbtarget = Hbfinal/(1 - ABL/EBV), where Hbtarget= Hb to achieve before surgery, Hbfinal = lowest Hb patient could tolerate taking into consideration his comorbidities (7 g/dL), ABL = volume of blood the surgeon estimated the patient would lose intra- and postoperatively (3000 mL), and EBV = estimated blood volume (75 mL/kg for an adult man). Spinal anesthesia was provided with a single shot hyperbaric bupivacaine and fentanyl. Acute hypervolemic hemodilution was achieved with lactated Ringer's solution and hydroxyethyl starch. To further minimize blood loss, controlled hypotension to a mean blood pressure of 55 mm Hg was achieved with a propofol infusion and tranexamic acid was administered. Surgical blood loss was estimated to be 2500 mL. Hb at the end of surgery was 13.3 g/dL; on postoperative day 5, 11.7 g/L. No blood products were utilized.

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.

Application of Acute Hypervolemic Hemodilution Combined with Nitroglycerin Controlled Hypotension in the Elderly Patients

To explore the possibility of acute hypervolemic hemodilution combined with controlled hypotension with Nitroglycerin in the elderly patients. 30 elderly patients are randomly divided into three groups: pure application AHH group (Group I), AHH combined use of nitroglycerin group (Group II) and the control group (Group III). The HR, ECG, BP, SpO2, CVP, FIB, PT, APTT were determined in anesthesia (T0), cut skin before (T1), operation after the main steps (T2), and 24 hours after surgery (T3). Group I and Group III patients CVP value of the blood dilution (T1, T2) than baseline (T0) were significantly increased (P<0.05), Group II patients CVP value had no significant changes. Group I and Group II in the actual amount of bleeding significantly lower than Group III (P <0.05). Group II patients without intraoperative blood transfusion, significantly lower than that in Group I (P<0.05), significantly lower than that in Group III (P <0.01). Group I, Group II and Group III patients, the platelet count and fibrinogen significantly reduced (P <0.05), while PT, APTT was significantly longer (P <0.05), but were within the normal range. Acute hypervolemic hemodilution combined with Nitroglycerin controlled hypotension can enhance the effect of blood conservation, especially Nitroglycerin can lessen volume load and possess better myocardial preservation.

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

Transfusion issues in a child of Jehovah's Witness parents: A neurosurgical case report

Jehovah's Witness (JW) is a religious Christian group whose members believe blood transfusion to be unholy and do not accept blood or its components, even if refusal of transfusion may prove to be life threatening. This belief is extended by them to their offspring too, despite the children being unaware of the implications of their parents' stand. A conflict arises between the parents' firm position against transfusion and the responsibility of the treating doctors towards the safety of these children. It raises several ethical and medico-legal issues, besides requiring a modified treatment plan. While there are well-defined practice guidelines and legal directives on this subject in the west, there is a paucity of similar literature in many other countries including India leading to major transfusion related conflicts. The perioperative protocol for the surgical management of a JW patient is directed towards achieving bloodless surgery. An anemic child of JW parents underwent excision of an intracranial third ventricular mass without blood transfusion at our hospital. We present here our experience in managing this case using blood-saving surgical and anesthetic methods including a meticulous surgical technique and acute hypervolemic hemodilution.

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

A clinical study of VOLUVEN and HES used for acute hypervolemic hemodilution on Hepatectomy

Objective To explore the safety and feasibility of VOLUVEN and HES used for acute hypervolemic hemodilution on selective Hepatectomy. Methods 42 patients （ASA Ⅰ - Ⅱ ） were randomized to the two groups （ Ⅰ , VOLUVEN group; Ⅱ , HES group） ,20 minutes before the operation, the two groups of patients underwent AHH with VOLUVEN and HES respectively at the same quantity and speed, and then the changes of haemodynamics, blood gas analysis,electrolyte and coagulation indexes were detected. Results In I group,the changes of HB,HCT, PLT,central venous pressure had statistical significance before and after AHH（ t = 7. 880,32. 257,7. 303,22. 812, all P = 0.000）. In Ⅱ group,the changes of HB, HCT, PLT, central venous pressure had statistical significance before and after AHH （ t = 5. 398,14.924,11. 171,5. 620, all P = 0. 000）. For inter-group, VOLUVEN has less effect than HES on central venous pressure （t = 2. 367,P = 0： 023）. Conclusion Using VOLUVEN or HES can keep hemodynamics stable and improve the ischemic tolerance for AHH in liver surgery. VOLUVEN has less effect on central venous pressure Key words: Hemodilution; Blood substitutes

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.

Effects of acute hypervolemic hemodilution and intra-operative cell salvage on orthopedic surgery patients

Objective To evaluate impacts of acute hypervolemic hemodilution (AHH) and intra-operative cell salvage (ICS) with 6％ volume fraction of hydroxyethyl starch (HES) on hemodynamics,blood saving efficiency and renal function of orthopedic surgery patients.Methods A total of 58 patients from orthopedic surgery were involved and randomly divided into AHH + ICS group (30 cases) and control group (28 cases).Changes of hemodynamic indices (HR,MAP and CVP) and renal function indices (BUN,BCr,UCr and ALB) in both groups were compared before operation (T0),immediately after operation (T1) and at postoperative 4 hours (T2),1 day (T3) and 2 days (T4).CCr was counted and intraoperative blood conservation was observed at each time point as well.Results HR,MAP and CVP of the two groups had no significant differences.Both groups showed some drop of HR (P ＜ 0.05),but an increase of MAP and CVP at T1-T4 (P ＜ 0.05),in contrast with levels at TO.BUN,BCr and ALB also showed insignificant differences between groups or within group at each time point.CCr in the control group showed no significant difference at each time point.On the contrary,CCr in the AHH + ICS group had a fall at T1-T4 and was declined to the lowest level at T2.CCr in the AHH + ICS group showed a recovery at T3-T4 and its level at T4 was still lower than that at TO,with no significant difference.CCr in the two groups showed insignificant difference at TO,but its level in the AHH + ICS group was lower than that in the control group at T1-T4,at T2 in particular (P ＜0.01).Moreover,CCr in the two groups was still significantly different at T4 (P ＜ 0.05).Renal function indices of the two groups were all within normal range at each time point.Intraoperative blood loss and unrine volume of the two groups had no significant differences,but intraoperative fluid requirement,allogenic blood transfusion volume and transfusion rate of AHH + ICS group were notably lower than those of control group (P ＜ 0.05 or P ＜0.01).Conclusions AHH plus ICS using HES are safe,effective and promising integrated blood conservation measures,which significantly reduces intraoperative allogenic blood transfusion volume and transfusion rate and has few impacts on fundamental vital signs and renal function.However,prolonged use of large dose of HES may do harm to renal function and therefore should be carefully considered in treatment of patients with severe renal dysfunction. Key words: Hemodilution; Renal circulation; Intraoperative cell salvage

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

Effects of acute hypervolemic hemodilution and low central venous pressure on blood loss and liver and renal function in patients undergoing keratectomy

Objective To evaluate the blood-saving effect of low central venous pressure (CVP) combined with acute hypervolemic hemodilution (AHHD) in patients undergoing hepatectomy.Methods Sixty ASA Ⅰ or Ⅱ patients undergoing hepatectomy for primary malignant hepatoma under epidural combined with general anesthesia were randomly divided into 3 groups (n=20 each); Control Group (Group A); LCVP Group (Group B) and LCVP+AHHD Group (Group C).Group A received crystalloid and colloid in a ratio of 1∶1 during the operation to maintain central venous pressure between 6 and 12 cmH2O; in group B,CVP was maintained between 2 and 5 cmH2O,CVP and MAP returned to normal levels by hypervolemic hemodilution with intravenous infusion of crystalloid and colloid after hepatectomy was completed.In Group C,Hematocrit( Hct) was maintained at 25％ ～ 30％ by administration of crystalloid and colloid after tracheal intubation.And CVP and MAP returned to normal levels by hypervolemic hemodilution with intravenous infusion of 6％hydroxyethyl starch 50 ml· kg-1 · h-1 for 10 minutes after hepatic lobectomy was completed.Hemoglobin ( Hb ),Hct,blood coagulation parameters (PT),Alanine aminotransferase (ALT)and renal blood urea nitrogen (BUN),creatinine (Cr)were determined-before operation,immediately after hepatic lobectomy was completed,at the end of operation,1 d and 7days after operation.The amount of infusion,the urine volume,intraoperative blood loss and complications should be recorded.Results Renal function of patients in three groups were within normal range.BUN fluctuations in Group C were more smoothly than in those Group B (P＜0.05),ALT recovery was better (P＜0.05) in Group B and Group C than that in Group A 7 days after operation.Compared with the Group A(1193.00 ± 443.05),the atnount of blood loss in group B (875.00 ± 415.01) and in group C (769.00 ± 405.57) were significantly less (P＜0.05),and urinary output in Group B was significantly less than that in Group C.Compared with the group A(642.00 ± 69.10),the amount of urinary output in Group B (435.50 ± 59.43) and in Group C(491.00 ± 64.70) were significantly less (P＜0.05),and Group C more than in Group B(P＜0.05).Conclusion The LCVP combined with AHHD during hepatic resection can effectively decrease intraoperative blood loss.What's more,the combination of the LCVP and AHHD provides better and safer protection for the functions of liver and kidney than the LCVP alone. Key words: Hemodilution; Central venous pressure; Hepatic lobectomy; Blood loss; Liver function; Renal function

Effect of acute hypervolemic hemodilution on renal function of emergency surgery patient's with brain injury

Objective To observe the effect of acute hypervolemic hemodilution (AHH) with two kinds of hydroxyethyl starches including Voluven and HES on the renal function of emergency surgery patients with brain injury.Methods This study involved 54 brain injury patients treated with emergency surgery,who were randomly divided into Voluven group ( AHH130 group),HES group ( AHH200 group) and Ringer's lactate group (LR group),with 18 patients in each group.All the patients were managed with inhalation anesthesia.ECG,MAP,CVP and SpO2 were observed in operation.The blood urea nitrogen (BUN),urine creatinine ( BCr,UCr),urinary albumin (ALB) and urinary α1-microglobulin ( α1-MG) were detected before AHH ( T0 ),at the end of operation ( T1 ),at 4 hours ( T2 ),day 1 ( T3 ),day 2 (T4) and day 3 (T5) after operation.The creatinine clearance (CCr) and fractional sodium clearance (FSC) were calculated and the urine output,fluid replacement,blood loss and blood transfusion recorded.Results The HR,CVP and MAP in the three groups were within the normal range of variation at all time points,with statistical difference for comparison between groups and within group ( P ＞ 0.05 ).There was no significant difference in urine output and blood loss,while the intraoperative fluid volume and blood transfusion in the AHH130 group and the AHH200 group were significantly less than those in the LR group (P ＜ 0.01 ).There was no statistical difference in aspects of BUN,BCr and urinary ALB at each time point between and within the three groups ( P ＞ 0.05 ).After treatment with AHH,the urinary α1-MG level in the AHH130 group and AHH200 group was significantly increased ( P ＜0.01 ),which was decreased at T5 but was still higher than that at T0 ( P ＜ 0.01 ),and was higher than that in the LR group at all time points (P＜0.05).After treatment with AHH,CCr was decreased in the AHH130 group and AHH200 group,which reached the lowest level at T2,with statistical difference compared with the levd at T0 ( P ＜0.01 ).Then,CCr was recovered to normal at T5.FSC in the three groups after AHH treatment was increased slightly and the most significantly at T2,which was not statistically different compared with that at T0 ( P ＞ 0.05) and FSC was not statistically different between and within groups at other time points (P ＞0.05).All the values about the renal function in all the groups changed within the normal range at each time point.Conclusions AHH with Voluven or HAES is a feasible and safe blood conservation measure that can significantly reduce the allogeneic blood transfusion but exert insignificant effect on renal function of the brain injury patients with normal renal function before emergency surgery. Key words: Craniocerebral trauma; Hemodilution; Hetastrarch; Renal function

Feasibility and safety of acute hypervolemic hemodilution in neurosurgical patients

To evaluate the preoperative effects of acute hypervolemic hemodilution (AHH) on intracranial pressure, cerebral oxygen supply-demand balance and cardiovascular functions of neurosurgical patients. Approved by hospital ethics committee, a total of 80 ASA grade I/II patients at our hospital during 2009, of either gender aged 18-60 yrs, undergoing elective craniotomy were recruited. The subjects were randomly divided equally into 2 groups: group H (hemodilution) and group C (control) (n = 40 each). After induction, 6% hydroxyethyl starch solution was infused at the rate of 24 ml×kg(-1)×h(-1) in group H, while patients in group C received compound electrolyte solution at the rate of 6 ml×kg(-1)×h(-1). Central venous pressure (CVP), cardiac output index (CI), stroke volume variation (SVV) and cerebral spinal fluid pressure (CSFP) were recorded at the following time points: T(Base) (before induction), T(0) (after induction and hemodynamic stabilization), T(30) (after infusion for 30 min) and T(60) (after infusion for 60 min). Blood samples from radial artery and jugular bulb were collected and calculated for systemic vascular resistance index (SVRI) and cerebral oxygen uptake rate (CERO(2)). The dosing frequency of vasoactive drugs was also recorded. CI in group H was significantly higher than that in group C (P < 0.01). No significant difference was found in both SjvO(2) and CERO(2) between groups and among different points of time (P > 0.05). At the end of AHH, CVP and CSFP were (12 ± 2.2) mm Hg and (20.0 ± 2.1) mm Hg respectively. They were significantly higher than that in group C (P < 0.01). Preoperative AHH in craniotomy will increase CI and maintain the balance of cerebral oxygen supply. But its clinical application is limited in the patient with high intracranial pressure due to the simultaneous increases in CVP and CSFP.

Pharmacokinetics of propofol in patients undergoing total hip replacement

The aim of the study was to investigate the effects of acute hypervolemic hemodilution (HHD) on the pharmacokinetics of propofol in patients undergoing total hip replacement. A total of 16 patients undergoing elective surgery for total hip replacement under general anesthesia in combination with epidural analgesia were randomly assigned to 2 groups: the control group (n = 8) or the HHD group (n = 8). All patients in both groups received lactated Ringer's solution before induction of general anesthesia. In the control group the conventional fluid replacement protocol was used. In the HHD group 4% succinylated gelatin was infused at the rate of 20ml•kg(-1)BW•h(-1 )with a targeted hematocrit of 30. Anesthesia was induced with midazolam 0.04mg•kg(-1), fentanyl 4µg•kg(-1) and propofol 1.5mg•kg(-1). Tracheal intubation was facilitated by infusion of succinylcholine 2mg•kg(-1). Anesthesia was maintained with isoflurane, fentanyl, vecuronium and epidural analgesia. Electrocardiogram (ECG), blood pressure (BP), blood oxygen saturation (SpO(2)), partial pressure of end-tidal carbon dioxide (P(ET)CO(2)) and central venous pressure (CVP) were monitored continuously. Blood samples were taken at 1, 2, 4, 6, 10, 15, 30, 45, 60, 75, 90, 120, 150, 180, 240, 300 and 360min after propofol administration to determine plasma concentrations of propofol by high performance liquid chromatography (HPLC). Plasma propofol concentrations were significantly lower in the HHD group than in the control group at 1, 2, 4, 6 and 10min after propofol administration (p < 0.01) while there were no significant differences in plasma propofol levels 15-360min after administration of propofol (p > 0.05). In the HHD group the volume of distribution of the central compartment (V(C)) increased significantly, elimination half-life (T(1/2) (γ)) was significantly prolonged, the elimination rate constant (K(10)) and the whole-body clearance (CL) were significantly decreased compared with the control group (p < 0.01 or 0.05). There were no significant differences of the half-life of the fast distribution phase (T(1/2) (α)), half-life of the slower distribution phase (T(1/2) (β)), K(12), K(21), K(13), K(31) and the area under the curve (AUC) (p > 0.05). The pharmacokinetic profile of propofol is best described by a three-compartment model in both groups using minimal Akaike information criteria (AIC). Acute HHD increases V(C), prolongs the T(1/2) (γ), and decreases K(10) and CL, which suggests that care must be taken when propofol is used in patients undergoing HHD. The induction dose should be increased, but the maintenance dose should be decreased. The time to emergency from anesthesia will likely be prolonged, especially in patients receiving prolonged continuous infusions.

Current Blood Salvage Technologies during Pelvic Repair

The introduction of current technologies into traumatology and orthopedics, anesthesiology and reanimatology and the accumulation of practical experience extend the feasibilities of highly skilled care to patients with pelvic fractures. Reconstructive operations that are one of the most complex and highly traumatic types in orthopedics are accompanied by massive intra- and postoperative blood loss. Its level is as high as 800 to 6000 ml. Until recently, blood loss has been compensated for with allogenic blood preparations. However, the complications resulting from the use of donor blood are universally known. This has caused indications for the use of blood preparations to be revised and a number of alternatives associated with the use of a patient&#8217;s blood to be developed. This alternative is current blood salvage technologies. Key words: autodonation, acute hypervolemic hemodilution, instrumental washed autoerythrocyte reinfusion, drainage blood reinfusion.