ACUTE NORMOVOLEMIC HEMODILUTION Aryeh Shander, MD, FCCM, FCCP Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital and Medical Center, Englewood, New Jersey Clinical Professor of Anesthesiology, Medicine and Surgery Mount Sinai School of Medicine, New York
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ACUTE NORMOVOLEMIC HEMODILUTION Aryeh Shander, MD, FCCM, FCCP Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital.
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Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine
Englewood Hospital and Medical Center,Englewood, New Jersey
Clinical Professor of Anesthesiology, Medicine and SurgeryMount Sinai School of Medicine, New York
ANH
• The technique• Formula or other targets• Fluid resuscitation, is there a
difference?• Induced anemia – safe or risk?• Anemia, perfusion and organ
function• ANH and PBM- outcomes
ANH
• As a blood conservation technique it cannot stand alone and must be accompanied by– Treatment of ANEMIA– Cell salvage and possible fractionation– Post operative management of anemia
and coagulation
ANH – The Debate
• ANH – controversial• ANH – variety of methods• ANH – unclear indications• ANH – risk not quantified• ANH – more work
• Preoperative ANH further attenuates myocardial injuries• ANH-induced cardioprotection:
– Optimization of preischemic myocardial oxygen delivery and/or consumption
– Postconditioning effects of endogenous EPOLicker M. et al. Transfusion. 2007 Feb;47(2):341-50
Perioperative time course of serum concentrations of total CPK (A), CK-MB (B), and cTnI (C) in the control ( ) and ANH ( )
groups. *p < 0.05, between the two groups; #p < 0.05, compared with baseline
Licker M. et al. Transfusion. 2007 Feb;47(2):341-50
ANH & CARDIAC DISEASE
Anh.jpg
Significant Intraoperative Predictors of TransfusionBased on Patients With a Preoperative Estimated Risk of
Transfusion 5%a
Risk Factors OR CI Multivariate p Value
CPB time 1.013 1.005–1.020 0.001No. of bypass grafts (3) 0.381 0.138–1.052 0.0626Total crystalloid (2,500 mL) 4.732 1.181–18.961 0.0282
Total ANH 0.999 0.998–0.999 0.0049
n 145 observations; 5 were excluded because of missing values for acovariate; Hosmer-Lemeshow statistic for lack of fit of this model has a p
value of 0.72, and the c statistic 0.802.ANH acute normovolemic hemodilution; CI confidence interval;
Moskowitz D, Klein J.J, Shander A et.al. Ann Thorac Surg 2004;77:626–34
Blood ConservationEnglewood Hospital and Medical Center
CABG OutcomesPBMP vs Non-PBMP
Moskowitz et al Ann Thorac Surg 2010
N=586
Outcome of ANH• Cost effective
– Monk TG, et al. Transfusion 1996;36(6):849-50ANH cost effective vs PAD in rad prostate surgery– Monk TG, et al. A&A 1997;85(5):953-8ANH replaces PAD– Monk TG, et al. Anesthesiology 1999;(1):24-33EPO, ANH and PAD – ANH least costly– Goodnough LT, et al. Vox Sang 1999;77(1):11-6RT of ANH vs PAD TKA – ANH less costly– Goodnough LT, et al. Transfsion
2000;40(9):1054-7RT ANH vs PAD in THA – ANH less $$
Clinical Studies
Meta-analysis of 24 randomized prospective studies of ANH in 1,218 patients
ANH reduced likelihood of allogeneic exposure and total units of allogeneic blood transfused
Bryson, G. L. et al., Anesth Analg 1998, 86: 9
Evaluation of Acute Normovolemic Hemodilution and Autotransfusion in
Neurosurgical Patients Undergoing Excision of Intracranial Meningiom
• Prospective randomized study• N = 40 (over 2 years)• Group I (Control Group) - Group II (ANH Group)
– Surgical blood loss in group I was 835.29 ± 684.37 ml vs 865 + 409.78 ml in group II
– Mean blood transfused in group I was 864.71 ± 349.89 ml vs. 165 ± 299.6 ml in group II [statistically significant (p<0.05)]
• ANH up to a target hematocrit of 30% is safe and effective in reducing the need for allogeneic blood
Naqash IA. Et al. J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):54-8
Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After
Pancreaticoduodenectomy Management
• N = 130 (July 2005 to May 2009) randomized to ANH or standard management (STDM)– Transfusion rates were similar (ANH = 16.9%, 30 units vs STD =
18.5%, 33 units; P = 0.82)– Morbidity (ANH = 49.2% vs STD = 47%, P = 0.86)– More grade-3 complications in patients undergoing ANH (32% vs
23.1% STD, P = 0.17)– Pancreatic anastomosis complications higher in the ANH group
(21.5% vs 7.7%, P = 0.045)
• ANH did not reduce allogeneic transfusions• Restrictive intravenous fluid management
during PD may help improve postoperative outcome
Fischer M. et al. Ann Surg. 2010 Dec;252(6):952-8
Acute normovolemic hemodilution in moderate blood loss surgery: a randomized controlled trial
• N = 155 patients undergoing elective hip surgery • Groups "ANH" (n = 78) or "standard transfusion" (n
= 77)• Allogeneic transfusion was necessary in 22 (29%)
standard transfusion patients and 15 (19%) ANH patients
• Postoperative complications:– 30 (38%) standard transfusion patients compared with 14
(18%) assigned to ANH group (OR, 0.3; 95% CI, 0.14-0.65; p = 0.009)
• The major difference between the groups was the frequency of infective complications
• ANH reduced postoperative complicationsBennett J. et al. Transfusion. 2006 Jul;46(7):1097-103
Acute Normovolemic Hemodilution (ANH)
• Safely reduces allogeneic transfusions and associated complications
• Cost effective procedure • Effective in all surgical procedures –
method dependent • Dramatically underutilized• No standard approach to date