Acute Normovolemic Hemodilution Research Articles

Autologous versus allogeneic blood transfusion: A comparative study of the peri-operative outcomes in a tertiary care hospital in South India amidst the COVID-19 pandemic

Autologous blood transfusion is known to have advantages over allogeneic transfusion. The COVID-19 pandemic intensified the already existing shortage of allogeneic blood supply. We carried out a study during this period with the aim to elicit the effects of autologous blood collection and transfusion, to compare the peri-operative outcomes of autologous and allogeneic transfusion practices and also to assess the influence of the autologous transfusion programme in the Blood Centre inventory. It was prospective observational comparative study among neurosurgical and vascular surgical patients in a tertiary care centre in South India. 141 patients were allocated into Group I (n = 71) who received autologous transfusion and those who received conventional allogeneic transfusion were clustered as Group II (n = 72) for analysis. We employed Acute Normovolemic Hemodilution (ANH), Pre-deposit Autologous Donation (PAD) and Intra-operative Cell Salvage (ICS) as various modalities for autologous blood collection. In our study, 43 (60.6%) from Group I received exclusive autologous blood transfusion, whereas 28 (39.4%) required additional allogeneic transfusion. No significant difference in hemoglobin, hematocrit, platelet count and INR were observed between the groups post transfusion. Significant difference was observed in the thoracoabdominal aortic aneurysm (TAAA) patients with respect to duration of ICU stay (2.7 ± 1.1 days in Group I and 6.2 ± 0.8 days in Group II; p = 0.002) and re-exploration due to bleeding (16.7% in Group I and 40% in Group II; p = 0.048). Autologous blood transfusion is safe and effective. It can be employed as routine practice and also during any acute shortage or pandemic.

A comparative study of stored arterial versus venous blood collected using the acute normovolemic hemodilution method in coronary artery bypass grafting patients in Iran.

In the present study, arterial and venous blood was collected from patients who were candidates for elective coronary artery bypass grafting (CABG); the blood was stored for 28 days and cellular, biomechanical, and hematological changes in blood were compared to determine whether stored arterial blood is superior to stored venous blood. The present follow-up comparative study included 60 patients >18 years of age, with hemoglobin >14 mg/dl and ejection fraction >40% who were candidates for CABG. After induction of anesthesia, 250 ml of arterial or venous blood was drawn from patients (arterial blood group and venous blood group). Laboratory blood samples were taken at specified times from the collected blood and re-injected into the patients after CABG. Significant differences were observed in pH, partial pressure of carbon dioxide (PCO2), partial pressure of oxygen (PO2), bicarbonate (HCO3), and glucose values at several time points between the groups. Other parameters such as urea and creatinine did not show any significant differences between the groups. Twenty-eight days of storage can have a negative effect on some of the cellular, biochemical, and hematological components of arterial and venous blood; however, the quality of stored arterial blood and venous blood does not differ significantly.

Evaluation of the Effect of Acute Normovolemic Hemodilution on Bleeding Rate and Short-Term Post-Operative Complication of Patient Who Underwent on-Pump Coronary Artery Bypass Graft Surgery

Evaluation of the Effect of Acute Normovolemic Hemodilution on Bleeding Rate and Short-Term Post-Operative Complication of Patient Who Underwent on-Pump Coronary Artery Bypass Graft Surgery

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis

BackgroundPerioperative bleeding and allogeneic blood transfusion are generally thought to affect the outcomes of patients. This meta-analysis aimed to determine the benefits and risks of several cardiovascular interventions in patients undergoing hepatectomy.MethodsIn this systematic review and meta-analysis, randomised controlled trials (RCTs) were searched in the Cochrane Library, Medline, Embase, and Web of Science to February 02, 2023. RCTs focused on cardiovascular interventions aimed at reducing blood loss or blood transfusion requirements during hepatectomy were included. The primary outcomes were perioperative blood loss amount, number of patients requiring allogeneic blood transfusion and overall occurrence of postoperative complications. The secondary outcomes were operating time, perioperative mortality rate, postoperative liver and kidney function and length of hospital stay.ResultsSeventeen RCTs were included in the analysis. A total of 841 patients who underwent hepatectomy in 10 trials were included in the comparative analysis between low central venous pressure (CVP) and control groups. The forest plots showed a low operative bleeding volume [(mean difference (MD): -409.75 mL, 95% confidence intervals (CI) -616.56 to -202.94, P < 0.001], reduced blood transfusion rate [risk ratio (RR): 0.47, 95% CI 0.34 to 0.65, P < 0.001], shortened operating time (MD: -13.42 min, 95% CI -22.59 to -4.26, P = 0.004), and fewer postoperative complications (RR: 0.76, 95% CI 0.58 to 0.99, P = 0.04) in the low CVP group than in the control group. Five and two trials compared the following interventions, respectively: ‘acute normovolaemic haemodilution (ANH) vs control’ and ‘autologous blood donation vs control’. ANH and autologous blood donation could not reduce the blood loss amount but greatly decreased the number of patients requiring allogeneic blood transfusion. No benefits were found in the rate of mortality and length of postoperative hospital stay in any of the comparisons.ConclusionLowering the CVP seems to be effective and safe in adult patients undergoing hepatectomy. ANH and autologous blood donation should be used as a part of blood management for suitable patients in certain circumstances.Trial registrationPROSPERO, CRD42022314061.

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management.

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension. Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience.

Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.

Large volume acute normovolemic hemodilution in patients undergoing cardiac surgery with intermediate-high risk of transfusion: A randomized controlled trial

Study Objective: To investigate whether large volume acute normovolemic hemodilution (L-ANH), compared with moderate acute normovolemic hemodilution (M-ANH), can reduce perioperative allogeneic blood transfusion in patients with intermediate-high risk of transfusion during cardiac surgery with cardiopulmonary bypass (CPB).Design: Prospective randomized controlled trial.Setting: University hospital.Patients: Patients with transfusion risk understanding scoring tool (“TRUST”) ≥2 points undergoing cardiac surgery with CPB in the Second Affiliated Hospital of Zhejiang University from May 2020 to January 2021 were included.Interventions: The patients were randomly assigned with a 1:1 ratio to M-ANH (5 to 8 mL/kg) or L-ANH (12 to 15 mL/kg).Measurements: The primary outcome was perioperative red blood cell (RBC) transfusion units. The composite outcome included new-onset atrial fibrillation, pulmonary infection, cardiac surgery associated acute kidney injury (CSA-AKI) class ≥2, surgical incision infection, postoperative excessive bleeding, and resternotomy. Main results: Total 159 patients were screened and 110 (55 L-ANH and 55 M-ANH) were included for final analysis. Removed blood volume of L-ANH is significantly higher than M-ANH (886 ± 152 vs. 395 ± 86 mL, P < 0.001). Perioperative RBC transfusion was median 0 unit ([25th, 75th] percentiles: 0–4.4) in M-ANH group vs. 0 unit ([25th, 75th] percentiles: 0–2.0) in L-ANH group (P = 0.012) and L-ANH was associated with lower incidence of transfusion (23.6% vs. 41.8%, P = 0.042, rate difference: 0.182, 95% confidence interval [0.007–0.343]). The incidence of postoperative excessive bleeding was significantly lower in L-ANH vs. M-ANH (3.6% vs. 18.2%, P = 0.029, rate difference: 0.146, 95% confidence interval [0.027–0.270]) without significant difference for other second outcomes. The volume of ANH was inversely related to perioperative RBC transfusion units (Spearman r = −0.483, 95% confidence interval [−0.708 to −0.168], P = 0.003), and L-ANH in cardiac surgery was associated with a significantly reduced risk of perioperative RBC transfusion (odds ratio: 0.43, 95% confidence interval: 0.19–0.98, P = 0.044).Conclusions: Compared with M-ANH, L-ANH during cardiac surgery inclined to be associated with reduced perioperative RBC transfusion and the volume of RBC transfusion was inversely proportional to the volume of ANH. In addition, LANH during cardiac surgery was associated with a lower incidence of postoperative excessive bleeding.

Patient Blood Management programs for post-partum hemorrhage.

Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.

Transfusion-free Strategies in Liver and Pancreatic Surgery: A Predictive Model of Blood Conservation for Transfusion Avoidance in Mainstream Populations.

The objective of this study is to (1) describe the techniques and prove the feasibility of performing complex hepatobiliary and pancreatic surgery on a Jehovah Witness (JW) population. (2) Describe a strategy that offsets surgical blood loss by the manipulation of circulating blood volume to create reserve whole blood upon anesthesia induction. Major liver and pancreatic resections often require operative transfusions. This limits surgical options for patients who do not accept major blood component transfusions. There is also growing recognition of the negative impact of allogenic blood transfusions. A 23-year, single-center, retrospective review of JW patients undergoing liver and pancreatic resections was performed. We describe perioperative management and patient outcomes. Acute normovolemic hemodilution (ANH) is proposed as an important strategy for offsetting blood losses and preventing the need for blood transfusion. A quantitative mathematical formula is developed to provide guidance for its use. One hundred one major resections were analyzed (liver n=57, pancreas n=44). ANH was utilized in 72 patients (liver n=38, pancreas n=34) with median removal of 2 units that were returned for hemorrhage as needed or at the completion of operation. There were no perioperative mortalities. Morbidity classified as Clavien grade 3 or higher occurred in 7.0% of liver resection and 15.9% of pancreatic resection patients. Deliberate perioperative management makes transfusion-free liver and pancreatic resections feasible. Intraoperative whole blood removal with ANH specifically preserves red cell mass, platelets, and coagulation factors for timely reinfusion. Application of the described JW transfusion-free strategy to a broader general population could lessen blood utilization costs and morbidities.

Jehovah's witness head and neck free flap reconstruction patient outcomes

BackgroundJehovah's Witnesses are members of a Christian religious denomination that rejects the transfusion of whole blood and component blood products. Given new transfusion-free strategies, Jehovah's Witness patients are undergoing free flap reconstructions with increased regularity. However, outcome data remains limited. With this study, we sought to examine post-operative outcomes in Jehovah's Witness patients undergoing free flap reconstruction of the head and neck, compare their outcomes to non-Jehovah's Witness patients, and enumerate strategies to enhance the safety of transfusion-free surgery. MethodsA retrospective chart review was carried out on 10 patients who identified as Jehovah's Witness and 63 patients who did not. Demographic information, pre-operative laboratory values, peri-operative resuscitative interventions, and peri-operative outcome measures were compiled. Descriptive data analysis, Mann-Whitney, Chi-square tests, and multivariate analysis were used. ResultsJehovah's Witness patients were significantly older than non-Jehovah's Witness patients (p = 0.03) and had significantly higher ASA scores (p = 0.009). Head and neck cancer was the primary surgical indication in both groups (p = 0.71). Jehovah's witness patients have significantly less intraoperative blood loss (p = 0.011) and lower post-operative hemoglobin (p = 0.002) compared to non-Jehovah's Witness patients. While Jehovah's Witness patients had significantly higher rates of severe anemia (p = 0.014), there was no significant difference between the two groups in other post-operative complications and readmission rates even in a multivariate analysis accounting for age and ASA score. ConclusionsFree flap microvascular reconstruction can be reliably performed on Jehovah's Witness head and neck patients without an increased risk of complication. Policies such as the use of non-blood volume expanders, albumin, Epogen, perioperative iron supplementation, cell saver and acute normovolemic hemodilution are key to ensuring good outcomes.

Transfusion-Free Strategy in Liver and Pancreatic Surgery: A Predictive Model of Blood Conservation for Transfusion Avoidance in Mainstream Populations

INTRODUCTION: Major liver and pancreatic resection often requires operative transfusion. This limits surgical options for patients who do not accept major blood component-transfusion. There is also growing recognition of the negative impact of allogenic blood transfusion. The objectives of this study are to: (1) Describe the techniques and prove the feasibility of performing complex hepatobiliary and pancreatic surgery on a Jehovah’s Witness (JW) population. (2) Describe a strategy that offsets operative blood loss by the manipulation of circulating blood volume to create reserve whole blood on anesthesia induction. METHODS: A 23-year, single-center, retrospective review of JW patients undergoing liver and pancreatic resection was performed. We describe perioperative management and patient outcomes. Acute normovolemic hemodilution (ANH) is proposed as an important strategy for offsetting blood loss and preventing the need for blood transfusion. A quantitative mathematical formula is developed to provide guidance for its use. RESULTS: One hundred one major resections were analyzed (liver n = 57, pancreas n = 44). ANH was used in 72 patients (liver n = 38, pancreas n = 34) with median removal of 2 units that were returned for hemorrhage as needed or at the completion of operation. There were no perioperative mortalities. Morbidity classified as Clavien grade 3 or higher occurred in 7.0% of liver resection and 15.9% of pancreatic resection patients. CONCLUSION: Deliberate perioperative management makes transfusion-free liver and pancreatic resection feasible. Intraoperative whole blood removal with ANH specifically preserves red blood cell mass, platelets, and coagulation factors for timely reinfusion. Application of the described JW transfusion-free strategy to a broader general population could lessen blood use cost and morbidity.

Hemodilution on microvascular oxygen delivery potential of the blood during coronary bypass surgery.

The hematocrit-to-whole blood viscosity ratio (Hct/WBV) reflects the blood O2 delivery potential (O2-DP). WBV is variable to the dynamic vascular shear rate (SR), 1-5/s at microcirculation and 300/s at larger vessels. To estimate the impact of hemodilution on the blood O2-DP to the myocardium, we analyzed the hemodilution-induced change of Hct/WBV at SR 5/s (Hct/WBV5) during off-pump coronary bypass (OPCAB) surgery. During OPCAB surgery (n = 21), 10% acute normovolemic hemodilution (HD 10%) was applied. Arterial blood samples were taken: one before and two after HD 10%. One of which after HD 10% underwent an additional 33% in vitro hemodilution (reaching 40% hemodilution in total, HD 40%). WBV of all blood samples was determined using a scan-capillary tube viscometer (Hemovister™). The changes of Hct/WBV5 were analyzed as a primary measure of the study and compared with those of Hct/WBV at SR 300/s (Hct/WBV300). Median[IQR] of Hct/WBV5 [3.5 (2.8-4.2)%/cPoise] was significantly increased by HD 10 and HD 40% [3.6 (3.2-4.6)%/cPoise and 4.2 (3.3-5.2)%/cPoise, respectively, all P < 0.001], but the degrees of changes after HD 10 and HD 40% were not different. Median[IQR] of Hct/WBV300 [10.3(8.6‒10.8)%/cPoise] was not changed by HD 10% [10.3(9.1-11.1)%/cPoise], but it was significantly decreased by HD 40% [8.4(7.4‒9.2)%/cPoise, P < 0.001]. The increased Hct/WBV5 suggests that 10-40% hemodilution improves the blood O2-DP to the myocardium during OPCAB surgery. The SR-specific discrepancy in Hct/WBV changes advocates using microvascular WBV and Hct/WBV to evaluate the blood O2-DP changes to the myocardium. Further study is warranted to assess the actual changes in myocardial O2 delivery.

Acute normovolemic hemodilution reduced the frequency and amount of perioperative allogeneic blood transfusion in pediatric and adolescent scoliosis surgery: a retrospective observational study.

The aim of the present study is to investigate whether acute normovolemic hemodilution (ANH) can reduce the frequency and amount of perioperative allogeneic blood transfusion (ABT) (intraoperative ABT and postoperative ABT until discharge from the hospital) in pediatric and adolescent scoliosis surgery. This single-center, retrospective, observational study included the perioperative data of 147 patients who were 18years old or younger and underwent scoliosis surgery. Patients were divided into groups according to whether they received ANH: i.e., an ANH group and control group. Propensity-score-adjusted multivariable logistic regression analysis was performed to determine whether ANH can reduce the frequency of perioperative ABT. A total of 125 patients were analyzed, 95 and 30 in the ANH and control group, respectively. The intraoperative/postoperative ABT frequency was significantly lower in the ANH group than in the control group (17.9% vs. 36.7%, p = 0.044). The amount of ABT [median (IQR): 0 (0, 0) mL/kg vs. 0 (0, 16.3) mL/kg, p = 0.033] was also significantly lower in the ANH group than in the control group. Propensity-score-adjusted multivariable logistic regression analysis indicated that ANH use [odds ratio: 0.15; 95% confidence interval: 0.03, 0.77; p = 0.023)] was associated with a lower risk of ABT after adjusting for intraoperative blood loss and duration of surgery. ANH use can reduce the frequency and amount of perioperative ABT in pediatric and adolescent scoliosis surgery.

Effects of room temperature and cold storage on the metabolic and haemostatic properties of whole blood for acute normovolaemic haemodilution.

BackgroundAcute normovolaemic haemodilution (ANH), as a blood-conservation technique, avoids the need for allogeneic blood transfusions. The historic practice of cold-storing type-O whole blood (WB) in military fields popularised the transfusion of refrigerated WB to treat acute bleeding. In this study, we compared the effects of room temperature (RT) and refrigeration up to 24 hours on the coagulation properties of WB for ANH.Materials and methodsEach WB sample, collected from 12 male volunteers, was divided into two parts, one stored at RT and the other refrigerated for 24 hours. Complete blood counts (CBC), blood gas levels, and coagulation profiles were measured, and rotational thromboelastometry (ROTEM) measurements were performed at the initial collection time point (baseline) and at 6, 12, and 24 hours after initial collection.ResultsThe preservation of platelet aggregation response induced by arachidonic acid and adenosine diphosphate was better in cold-stored WB compared to that in RT-stored WB. The platelet aggregation response induced by thrombin receptor-activating peptide 6 was significantly decreased in all samples after 24 hours of storage when compared with that at baseline. The lactate levels in WB stored at RT increased significantly after 6 hours of storage compared to that of cold-stored samples. There were no significant differences in CBC, coagulation parameters, and ROTEM variables between the cold-stored and RT-stored WB samples.ConclusionWB for ANH stored in the refrigerator showed better metabolic characteristics after 6 hours of storage and better aggregation response after 12 hours of storage than WB stored at RT.

Scoliotic deformity of the spine: epidemiology, classification, surgical treatment, prediction and correction of intraoperative blood loss

In this review are discussed the most important questions of diagnostics, surgical treatment and complications in the context of anaesthesia choice and performance in children and adolescents with different variants of vertebral scoliotic deformity. Vertebral scoliotic deformity is a multi-etiological disease and significant clinical problem due to frequency and severity of complications when disease progresses. Surgery is performed in severe and super severe scoliotic deformity when conservative treatment is not effective. Surgical treatment of severe scoliotic deformity allows to improve physiological function of vertebral column and internal organs’ function, improve quality of life and increase life expectancy. Surgical treatment of severe scoliotic deformity is one of the most complex problem in traumatology and orthopedics which requires multidisciplinary coordination of surgeon, anesthesiologist, narrow specialists and the patient at every step of treatment. The most significant problems in surgical treatment of severe scoliotic deformity are forecasting and blood loss management during the operation and in post-operative care which could reach several circulating blood volumes. The problems of blood loss minimization are discussed: patient’s position on operating table, acute normovolemic haemodilution, managed hypotension, use of antifibrinolythic medications, blood collection and re-infusion, blood transfusion. Blood loss forecasting is an important instrument to get a proactive information to develop personalized approach to patient’s care with assessment of intraoperative blood loss, risk of hemorrhagic shock and disseminated intravascular coagulation syndrome.

Does Autologous Transfusion Decrease Allogeneic Transfusion in Liposuction Surgery of Lymphedema Patients?

Background and ObjectiveLiposuction is an effective treatment for fat disposition in lymphedema. Blood transfusion has been seldom investigated in lymphedema liposuction surgery. The purpose of the study was to analyze clinical factors associated with blood transfusion in liposuction surgery of lymphedema patients and compare the autologous and allogeneic transfusion patterns.MethodsA total of 1,187 cases of liposuction due to lymphedema were recruited. Demographic, laboratory tests and operation information were collected. Patients were divided into a transfusion and a non-transfusion group. Different transfusion patterns were compared and analyzed.ResultsBetween the two groups, there is a significant difference in postoperative hemoglobin levels, and as well as gender, age, surgery duration, body weight change, intraoperative transfusion volume and blood loss, hospital length of stay, and surgical site distribution. There is a significant difference in the comparison of hospital stay length, autologous transfusion volume, combined allogeneic volume, operative blood loss, intraoperative transfusion volume, and change in hemoglobin levels between predonation and acute normovolemic hemodilution (ANH) transfusion. In comparison with the allogeneic transfusion-only patients, the mean allogeneic transfusion volume in either ANH group, predonated transfusion group, or mixed group is statistically lower. Allogeneic transfusion volume in the predonated-only group is significantly lower than that of either the ANH-only group or the mixing ANH with predonation group. Ordinary least squares regression analysis suggests that autologous transfusion in the ANH-only mode is statistically associated with allogeneic transfusion.ConclusionsThis study described the blood transfusion in lymphedema liposuction surgery and compared autologous and allogeneic transfusion patterns in these patients. Autologous transfusion can reduce the transfusion volume of allogeneic blood and might be a beneficial mode of transfusion in these patients.

Pro: Acute Normovolemic Hemodilution Should Be Used in Infective Endocarditis Patients Coming for Primary or Redo Cardiac Surgery

ACUTE NORMOVOLEMIC HEMODILUTION (ANH) is a blood conservation strategy well-known to reduce allogeneic blood transfusion. More specifically, perioperative autologous whole blood collection and reinfusion during cardiac surgery have been shown to reduce allogeneic red blood cell (RBC) transfusions (4% v 44% in a control group). 1 Henderson RA Judd M Strauss ER et al. Hematologic evaluation of intraoperative autologous blood collection and allogeneic transfusion in cardiac surgery. Transfusion. 2021; 61: 788-798 Crossref PubMed Scopus (8) Google Scholar In addition, the use of ANH has the potential to improve coagulation parameters, thereby reducing the administration of clotting factors and other blood products. 1 Henderson RA Judd M Strauss ER et al. Hematologic evaluation of intraoperative autologous blood collection and allogeneic transfusion in cardiac surgery. Transfusion. 2021; 61: 788-798 Crossref PubMed Scopus (8) Google Scholar , 2 Barile L Fominskiy E Di Tomasso N et al. Acute normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis of randomized trials. Anesth Analg. 2017; 124: 743-752 Crossref PubMed Scopus (93) Google Scholar , 3 Henderson RA Mazzeffi MA Strauss ER et al. Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: A propensity score matched analysis. Transfusion. 2019; 59: 2023-2029 PubMed Google Scholar This has been attributed to the shielding effect of ANH on platelets and clotting factors from activation, consumption, and shearing stress injury from the cardiopulmonary bypass (CPB) circuit. ANH also improves tissue perfusion by hemodilution, enhances body's tolerance to blood loss, and likely reduces surgical blood loss. 4 Zhou J. A review of the application of autologous blood transfusion. Braz J Med Biol Res. 2016; 49: e5493 Crossref PubMed Scopus (26) Google Scholar Other potential benefits of ANH are bone marrow stimulation and the endogenous regeneration of hematopoietic cells, leading to faster recovery from anemia after surgery.

Con: Acute Normovolemic Hemodilution Should not be used in Infective Endocarditis

Acute normovolemic hemodilution (ANH) was first used in the 1970’s as a blood conservation strategy for cardiac surgery. Despite five decades of consistent use, there remains an overall lack of strong evidence for its utility and reliability in improving perioperative outcomes. Multiple individual trials and three large scale meta-analyses have identified a potential improvement in the rates of allogeneic blood transfusion with ANH, but provide no evidence regarding improvements in morbidity and mortality, length of stay, and cost.1 While strong data is lacking to support its widespread use, it remains an appealing and safe option for patients with a high starting hematocrit in whom a large volume of surgical blood loss is expected. Although it is generally contraindicated in patients with sepsis or endocarditis, our colleagues have posited that it could be a useful technique for blood conservation in this population. Here, however, we will identify and discuss specific drawbacks for ANH in endocarditis, including preload reduction, the endotoxin burden, septic transfusion reactions, and cytokine release. Given these special issues, in addition to the already present lack of consensus, the risks outweigh the benefits for ANH in patients with endocarditis.

Hemodilution in high-risk cardiac surgery: Laboratory values, physiological parameters, and outcomes.

Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability, and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N=66) and non-ANH controls (N=103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass. Intraoperatively, the ANH group received more albumin (p=.04) and vasopressor medications (p=.01), while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO2 ) values were similar before and after hemodilution. During bypass, rSO2 were discretely lower in the ANH versus control group (right rSO2 p =.03, left rSO2 p=.05). No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, intensive care unit length of stay, kidney injury, stroke, or infection were demonstrated. This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better understanding and wider acceptance of ANH protocols in high-risk cardiac surgeries.