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Kuo K, Palmer L. Pathophysiology of hemorrhagic shock. J Vet Emerg Crit Care (San Antonio) 2022; 32:22-31. [PMID: 35044060 DOI: 10.1111/vec.13126] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 03/11/2017] [Accepted: 06/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hemorrhagic shock is a common condition that may lead to hemodynamic instability, decreased oxygen delivery, cellular hypoxia, organ damage, and ultimately death. CLINICAL IMPORTANCE This review addresses the pathophysiology of hemorrhagic shock. Hemorrhagic shock can be rapidly fatal and is the leading cause of death in human trauma patients. Understanding the pathophysiology of hemorrhagic shock is imperative in understanding the current hemostatic and resuscitative strategies and is foundational to the development of new therapeutic options. KEY POINTS Shock is a state of inadequate cellular energy production and can be triggered by many causes Both traumatic and non-traumatic causes of hemorrhage can lead to the development of hemorrhagic shock Prompt recognition and attenuation of hemorrhage is paramount in preventing the onset or potentiation of hemorrhagic shock Acute hemorrhage produces distinct physiological responses depending on the magnitude and rate of hemorrhage. Hemorrhagic shock may be directly related to the initial injury but may also be exacerbated and complicated by a post-traumatic coagulopathy, termed acute traumatic coagulopathy.
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Affiliation(s)
- Kendon Kuo
- Wilford and Kate Bailey Small Animal Teaching Hospital, Auburn University, Auburn, Alabama, USA
| | - Lee Palmer
- Clinical Sciences, Auburn University, Auburn, Alabama, USA
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Tyan P, Taher A, Carey E, Sparks A, Radwan A, Amdur R, Tamim H, Gu A, Robinson H, Moawad GN. The effect of anemia severity on postoperative morbidity among patients undergoing laparoscopic hysterectomy for benign indications. Acta Obstet Gynecol Scand 2019; 99:112-118. [PMID: 31449328 DOI: 10.1111/aogs.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/03/2019] [Accepted: 08/05/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION One-third of non-pregnant women worldwide are anemic.1 Anemia is a known independent risk factor for postoperative morbidity.2 Given that the vast majority of hysterectomies are not performed in the emergency setting, we designed this study to evaluate the effect of preoperative anemia on postoperative morbidity following laparoscopic hysterectomy performed for benign indications. Our main goal is to encourage surgeons to use anemia-corrective measures before surgery when feasible. MATERIAL AND METHODS Retrospective cohort study of 98 813 patients who underwent a laparoscopic hysterectomy between 2005 and 2016 for benign indications identified through the American College of Surgeons National Surgical Quality Improvement Program. Anemia was examined as a function of hematocrit and was analyzed as an ordinal variable stratified by anemia severity as mild, moderate or severe. Associations between preoperative anemia and patient demographics, preoperative comorbidities and postoperative outcomes were evaluated using univariate analyses. Multivariable logistic regression models were used to identify independent associations between hematocrit level and postoperative outcomes after adjusting for confounding covariates. At the multivariable logistic regression level, anemia severity was analyzed using hematocrit as a continuous variable to assess the independent association between each 5% decrease in hematocrit level and several postoperative morbidities. RESULTS Of the 98 813 patients who met our inclusion and exclusion criteria, 19.5% were anemic. A lower preoperative hematocrit was associated with higher body mass index, younger age, Black or African American race, longer operative times, and multiple other medical comorbidities. After appropriate regression modeling, anemia was identified as an independent risk factor for extended length of stay, readmission and composite morbidity after surgery. CONCLUSIONS Preoperative anemia is common among patients undergoing laparoscopic hysterectomy. Preoperative anemia increases patients' risk for multiple postoperative comorbidities. Given that most hysterectomies are performed in the elective setting, gynecologic surgeons should consider the use of anemia-corrective measures to minimize postoperative morbidity.
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Affiliation(s)
- Paul Tyan
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ali Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Erin Carey
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew Sparks
- Department of Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Amr Radwan
- Department of Internal Medicine, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Richard Amdur
- Department of Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Alex Gu
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Hannah Robinson
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Gaby N Moawad
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The George Washington University, Washington, DC, USA
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A Modern View on the Diagnostic and Therapy Anemia Chronic Diseases Problems. Fam Med 2019. [DOI: 10.30841/2307-5112.3.2019.178588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Meier J. Blood transfusion and coagulation management. Best Pract Res Clin Anaesthesiol 2016; 30:371-9. [PMID: 27650346 DOI: 10.1016/j.bpa.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/07/2016] [Indexed: 01/01/2023]
Abstract
Despite impressive progress in surgical technique, aortic surgery is still associated with relatively high morbidity and mortality. One of the most important contributors to this phenomenon is the triad of bleeding, anemia, and transfusion. All three factors are known to influence the outcome of aortic surgery to a great extent. However, over the last few years a multidisciplinary, multimodal concept has been established, which enables the physician to avoid bleeding, anemia, and transfusion as much as possible. The concept of "patient blood management" combines several established measures with the potential to improve perioperative outcome. This chapter describes these measures with regard to aortic surgery and assesses their respective efficacy.
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Affiliation(s)
- Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Krankenhausstrasse 9, 4021 Linz, Austria.
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Kariya T, Ito N, Kitamura T, Yamada Y. Recovery from Extreme Hemodilution (Hemoglobin Level of 0.6 g/dL) in Cadaveric Liver Transplantation. ACTA ACUST UNITED AC 2015; 4:132-6. [PMID: 25974417 PMCID: PMC4548248 DOI: 10.1213/xaa.0000000000000132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Decompensated hepatic failure occurred in a patient with a rare blood type. The patient had extreme hemodilution due to massive bleeding during liver transplantation. A shortage of matched and universal donor blood prompted us to transfuse albumin and fresh frozen plasma for intravascular volume resuscitation. The lowest hemoglobin was 0.6 g/dL, accompanied by ST depression and a serum lactate of 100 mg/dL. The accuracy of the measured value of 0.6 g/dL was confirmed. However, the patient recovered from this critical situation after transfusion, and he was eventually discharged from the hospital without significant sequelae. Maintaining normovolemia, administering pure oxygen, ensuring appropriate anesthetic depth, and maintaining minimal inotropic support were essential for this patient's survival during massive bleeding.
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Affiliation(s)
- Taro Kariya
- From the Departments of *Cardiovascular Medicine and †Anesthesia and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan; and ‡Department of Anesthesiology, Toho University Sakura Medical Center, Sakura, Chiba, Japan
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Najafi M, Faraoni D. Hemoglobin optimization and transfusion strategies in patients undergoing cardiac surgery. World J Cardiol 2015; 7:377-382. [PMID: 26225197 PMCID: PMC4513488 DOI: 10.4330/wjc.v7.i7.377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/07/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
Although red blood cells (RBCs) transfusion is sometimes associated with adverse reactions, anemia could also lead to increased morbidity and mortality in high-risk patients. For these reasons, the definition of perioperative strategies that aims to detect and treat preoperative anemia, prevent excessive blood loss, and define “optimal” transfusion algorithms is crucial. Although the treatment with preoperative iron and erythropoietin has been recommended in some specific conditions, several controversies exist regarding the benefit-to-risk balance associated with these treatments. Further studies are needed to better define the indications, dosage, and route of administration for preoperative iron with or without erythropoietin supplementation. Although restrictive transfusion strategies in patients undergoing cardiac surgery have been shown to effectively reduce the incidence and the amount of RBCs transfusion without increase in side effects, some high-risk patients (e.g., symptomatic acute coronary syndrome) could benefit from higher hemoglobin concentrations. Despite all efforts made last decade, a significant amount of work remains to be done to improve hemoglobin optimization and transfusion strategies in patients undergoing cardiac surgery.
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Thoracic epidural anesthesia with ropivacaine does not compromise the tolerance of acute normovolemic anemia in pigs. Anesthesiology 2014; 121:765-72. [PMID: 24937075 DOI: 10.1097/aln.0000000000000340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The initial treatment of an acute blood loss with acellular fluids leads to the dilution of the red cell mass remaining in the vasculature, that is, to acute normovolemic anemia. Whether the compensation and, thus, the tolerance of acute anemia, are affected by sympathetic block induced by thoracic epidural anesthesia has not yet been investigated. METHODS Eighteen anesthetized and mechanically ventilated pigs were instrumented with thoracic epidural catheters and randomly assigned to receive an epidural injection of either 5-ml ropivacaine 0.2% (n = 9) aiming for a Th5-Th10 block or saline (n = 9) followed by continuous epidural infusion of 5 ml/h of either fluid. Subsequently, acute normovolemic anemia was induced by replacement of whole blood with 6% hydroxyethyl starch solution until a "critical" limitation of oxygen transport capacity was reached as indicated by a sudden decrease in oxygen consumption. The critical hemoglobin concentration quantified at this time point was the primary endpoint; secondary endpoints were hemodynamic and oxygen transport parameters. RESULTS Thoracic epidural anesthesia elicited only a moderate decrease in mean arterial pressure and cardiac index and a transient decrease in oxygen extraction ratio. During progressive anemia, the compensatory increases in cardiac index and oxygen extraction ratio were not compromised by thoracic epidural anesthesia. Critical hemoglobin concentration was reached at identical levels in both groups (ropivacaine group: 2.5 ± 0.6 g/dl, saline group: 2.5 ± 0.6 g/dl). CONCLUSION Thoracic epidural anesthesia with ropivacaine 0.2% does not decrease the tolerance to acute normovolemic anemia in healthy pigs. The hemodynamic compensation of acute anemia is fully preserved despite sympathetic block, and the critical hemoglobin concentration remains unaffected.
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Crystal GJ. Regional tolerance to acute normovolemic hemodilution: evidence that the kidney may be at greatest risk. J Cardiothorac Vasc Anesth 2014; 29:320-7. [PMID: 25440629 DOI: 10.1053/j.jvca.2014.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the regional tolerance to acute normovolemic hemodilution (ANH). DESIGN Prospective animal study. SETTING University research laboratory. PARTICIPANTS Nine anesthetized (isoflurane) dogs. INTERVENTIONS Hematocrit reduced in 10% decrements using dextran-for-blood exchange until cardiac insufficiency observed. MEASUREMENTS AND MAIN RESULTS Cardiac index (CI) was measured using thermodilution and regional blood flow (RBF) in myocardium, brain, spinal cord, kidney, liver, duodenum, pancreas, spleen, skeletal muscle, and skin with radioactive microspheres. Oxygen delivery (DO2) was calculated from the product of respective blood flow and arterial oxygen content. Systemic oxygen extraction (EO2) and oxygen consumption (VO2) were calculated. Increases in CI during ANH were inadequate to prevent decreases in systemic DO2; however, an increased systemic EO2 maintained VO2 during graded ANH to hematocrit<10%. In the myocardium, brain, and spinal cord, increases in RBF were sufficient to maintain DO2 across the entire range of hematocrits, but this was not the case in the other organs studied. Of note, renal DO2 first decreased at a hematocrit of 30% and was only 25% of baseline at a hematocrit of 10%. CONCLUSIONS During graded ANH, increases in RBF were sufficient to maintain DO2 in only the heart, brain, and spinal cord. The especially marked decrease in DO2 in the kidney, combined with previous physiologic studies demonstrating its inability to augment EO2, suggest that this organ may be the most at risk of hypoxic damage during ANH.
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Affiliation(s)
- George J Crystal
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL; Departments of Anesthesiology and of Physiology and Biophysics, University of Illinois College of Medicine, Chicago, IL.
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Hubbell JAE, Muir WW. Oxygenation, oxygen delivery and anaesthesia in the horse. Equine Vet J 2014; 47:25-35. [DOI: 10.1111/evj.12258] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/26/2014] [Indexed: 11/30/2022]
Affiliation(s)
- J. A. E. Hubbell
- The Department of Veterinary Clinical Sciences; College of Veterinary Medicine; The Ohio State University; Columbus USA
| | - W. W. Muir
- Veterinary Clinical Pharmacology Consulting Services; Columbus Ohio USA
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Hare GMT. Tolerance of anemia: understanding the adaptive physiological mechanisms which promote survival. Transfus Apher Sci 2013; 50:10-2. [PMID: 24433778 DOI: 10.1016/j.transci.2013.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Acute anemia and hemodilution are associated with increased organ injury (brain, kidney) and mortality in patients undergoing surgery. A more complete understanding of the adaptive physiological mechanisms which maintain tissue oxygen delivery, and the hemoglobin concentration at which these mechanisms are overwhelmed, would help to direct treatments to improve event free survival in patients who experience acute anemia. Adaptive cardiovascular and cellular responses are key to maintaining survival during acute anemia. We have identified neuronal nitric oxide synthase (nNOS) and hypoxia inducible factor (HIF) promote survival during acute anemia in animal models. In addition, activation of tissue nNOS may promote oxidation of hemoglobin to methemoglobin: a potential biomarker of anemia-induced tissue hypoxia. We continue to explore the possibility that methemoglobin, and other hypoxic signaling molecules, may be biomarkers of anemia induced tissue hypoxia which can be used to guide optimal treatment of anemic patents.
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Affiliation(s)
- Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Physiology, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.
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Meier J, Gombotz H. Pillar III – Optimisation of anaemia tolerance. Best Pract Res Clin Anaesthesiol 2013; 27:111-9. [DOI: 10.1016/j.bpa.2013.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 01/28/2013] [Accepted: 02/13/2013] [Indexed: 10/27/2022]
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Pape A, Kutschker S, Kertscho H, Stein P, Horn O, Lossen M, Zwissler B, Habler O. The choice of the intravenous fluid influences the tolerance of acute normovolemic anemia in anesthetized domestic pigs. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R69. [PMID: 22546374 PMCID: PMC3681398 DOI: 10.1186/cc11324] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 03/02/2012] [Accepted: 04/30/2012] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The correction of hypovolemia with acellular fluids results in acute normovolemic anemia. Whether the choice of the infusion fluid has an impact on the maintenance of oxygen (O₂) supply during acute normovolemic anemia has not been investigated so far. METHODS Thirty-six anesthetized and mechanically ventilated pigs were hemodiluted to their physiological limit of anemia tolerance, reflected by the individual critical hemoglobin concentration (Hbcrit). Hbcrit was defined as the Hb-concentration corresponding with the onset of supply-dependency of total body O₂-consumption (VO₂). The hemodilution protocol was randomly performed with either tetrastarch (6% HES 130/0.4, TS-group, n = 9), gelatin (3.5% urea-crosslinked polygeline, GEL-group, n = 9), hetastarch (6% HES 450/0.7, HS-group, n = 9) or Ringer's solution (RS-group, n = 9). The primary endpoint was the dimension of Hbcrit, secondary endpoints were parameters of central hemodynamics, O₂ transport and tissue oxygenation. RESULTS In each animal, normovolemia was maintained throughout the protocol. Hbcrit was met at 3.7 ± 0.6 g/dl (RS), 3.0 ± 0.6 g/dl (HS P < 0.05 vs. RS), 2.7 ± 0.6 g/dl (GEL, P < 0.05 vs. RS) and 2.1 ± 0.4 g/dl (TS, P < 0.05 vs. GEL, HS and RS). Hemodilution with RS resulted in a significant increase of extravascular lung water index (EVLWI) and a decrease of arterial oxygen partial pressure (paO₂), and O₂ extraction ratio was increased, when animals of the TS-, GEL- and HS-groups met their individual Hbcrit. CONCLUSIONS The choice of the intravenous fluid has an impact on the tolerance of acute normovolemic anemia induced by acellular volume replacement. Third-generation tetrastarch preparations (e.g., HES 130/0.4) appear most advantageous regarding maintenance of tissue oxygenation during progressive anemia. The underlying mechanism includes a lower degree of extravasation and favourable effects on microcirculatory function.
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Affiliation(s)
- Andreas Pape
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Management, JW Goethe-University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt/Main, 60590, Germany.
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Pape A, Kertscho H, Stein P, Lossen M, Horn O, Kutschker S, Zwissler B, Habler O. Neuromuscular blockade with rocuronium bromide increases the tolerance of acute normovolemic anemia in anesthetized pigs. ACTA ACUST UNITED AC 2011; 48:16-25. [PMID: 22189343 DOI: 10.1159/000333797] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 09/15/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND The patient's individual anemia tolerance is pivotal when blood transfusions become necessary, but are not feasible for some reason. To date, the effects of neuromuscular blockade (NMB) on anemia tolerance have not been investigated. METHODS 14 anesthetized and mechanically ventilated pigs were randomly assigned to the Roc group (3.78 mg/kg rocuronium bromide followed by continuous infusion of 1 mg/kg/min, n = 7) or to the Sal group (administration of the corresponding volume of normal saline, n = 7). Subsequently, acute normovolemic anemia was induced by simultaneous exchange of whole blood for a 6% hydroxyethyl starch solution (130/0.4) until a sudden decrease of total body O(2) consumption (VO(2)) indicated a critical limitation of O(2) transport capacity. The Hb concentration quantified at this time point (Hb(crit)) was the primary endpoint of the protocol. Secondary endpoints were parameters of hemodynamics, O(2) transport and tissue oxygenation. RESULTS Hb(crit) was significantly lower in the Roc group (2.4 ± 0.5 vs. 3.2 ± 0.7 g/dl) reflecting increased anemia tolerance. NMB with rocuronium bromide reduced skeletal muscular VO(2) and total body O(2) extraction rate. As the cardiac index increased simultaneously, total body VO(2) only decreased marginally in the Roc group (change of VO(2) relative to baseline -1.7 ± 0.8 vs. 3.2 ± 1.9% in the Sal group, p < 0.05). CONCLUSION Deep NMB with rocuronium bromide increases the tolerance of acute normovolemic anemia. The underlying mechanism most likely involves a reduction of skeletal muscular VO(2). During acellular treatment of an acute blood loss, NMB might play an adjuvant role in situations where profound stages of normovolemic anemia have to be tolerated (e.g. bridging an unexpected blood loss until blood products become available for transfusion).
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Affiliation(s)
- A Pape
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Management, J.W. Goethe University Hospital, Frankfurt a.M., Germany
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Tocancipá DR, Ferrer AP. Técnicas de ahorro sanguíneo en cirugía. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2011. [DOI: 10.5554/rca.v39i4.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Champion T, Pereira Neto GB, Camacho AA. Effects of acute normovolemic anemia on hemodynamic parameters and Acid-base balance in dogs. Vet Med Int 2011; 2011:829054. [PMID: 21547226 PMCID: PMC3087501 DOI: 10.4061/2011/829054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/07/2011] [Accepted: 02/18/2011] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to evaluate the hemodynamic and acid-base status of dogs subjected to acute normovolemic anemia. The dogs (n = 10) were evaluated 15 minutes and 24 hours after induction of anemia (hematocrit below 18%) with blood withdrawal and simultaneously replacement of same volume of Ringer's lactate solution and hydroxyethyl starch-based solution in a 2 : 1 ratio. The cardiac output was measured by Doppler echocardiography and blood pressure by oscillometric device, and posteriorly hemodynamic parameters were calculated. The anemic groups had increase in cardiac index (P < .05) (3.82 ± 1.05 to 5.86 ± 1.49 and 5.81 ± 1.63 L/min × m2) and decreases (P < .05) in the indices of total peripheral resistance (6797.81 ± 3060.22 to 3220.14 ± 1275.02 and 3887.74 ± 1394.89 dina·seg/cm5 × m2) and oxygen delivery (7942.84 ± 3344.00 to 4021.68 ± 1627.00 and 4430.82 ± 1402.61 mL/min × m2), respectively. There were no significant changes in pH, but PaO2 and SaO2 values were increased, and PaCO2 reduced in anemic dogs (P < .05). Therefore, acute normovolemic anemia can create significant hemodynamic changes and despite some hemogasometric changes, there were no changes in the acid-base status in dogs.
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Affiliation(s)
- Tatiana Champion
- Department of Animal Surgery and Clinical Sciences, Faculty of Agricultural and Veterinary Sciences (FCAV), São Paulo State University (UNESP), Via de Acesso Professor Paulo Donato Castellane, km 5, 14884-900 Jaboticabal, SP, Brazil
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Habler O, Voss B. [Perioperative management of Jehovah's Witness patients. Special consideration of religiously motivated refusal of allogeneic blood transfusion]. Anaesthesist 2010; 59:297-311. [PMID: 20379694 DOI: 10.1007/s00101-010-1701-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The religious organization of Jehovah's Witnesses numbers more than 7 million members worldwide, including 165,000 members in Germany. Although Jehovah's Witnesses strictly refuse the transfusion of allogeneic red blood cells, platelets and plasma, Jehovah's Witness patients may nevertheless benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The present review describes the perioperative management of surgical Jehovah's Witness patients aiming to prevent fatal anemia and coagulopathy. The cornerstones of this concept are 1) education of the patient about blood conservation techniques generally accepted by Jehovah's Witnesses, 2) preoperative optimization of the cardiopulmonary status and correction of preoperative anemia and coagulopathy, 3) perioperative collection of autologous blood, 4) minimization of perioperative blood loss and 5) utilization of the organism's natural anemia tolerance and its acute accentuation in the case of life-threatening anemia.
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Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt am Main.
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Gredilla E, Pérez-Ferrer A, Canser E, Alonso E, Martínez Serrano B, Gilsanz F. [Treating severe acute anemia due to vaginal bleeding in the Jehovah's Witness: a report of 2 cases]. ACTA ACUST UNITED AC 2010; 56:632-4. [PMID: 20151526 DOI: 10.1016/s0034-9356(09)70480-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
For reasons of religious belief, Jehova's Witnesses do not accept blood transfusions or the infusion of blood products. In situations in which severe, life-threatening anemia develops, patient refusal to receive a transfusion can create serious ethical and legal problems. The principle of patient autonomy, which implies the freedom to accept or reject treatment, comes into conflict with the physician's obligation to safeguard the patient's life using all means possible. We report 2 cases of severe anemia in Jehova's Witnesses. One was due to menorrhagia and the other to postpartum bleeding. The physician should be aware of alternatives to infusion of blood products and know how to cope with an unexpected critical event in these patients. The measures we took were effective in our patients. In the case of menorrhagia, hormone treatment is effective when the woman wishes to preserve the ability to conceive and avoid surgery (endometrial ablation and hysterectomy). In postpartum bleeding refractory to conservative treatment, selective embolization of bleeding vessels may make it unnecessary to resort to more aggressive treatment, such as obstetric hysterectomy.
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Affiliation(s)
- E Gredilla
- Servicio Anestesiología y Reanimación, Hospital Universitario Maternal La Paz, Madrid.
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Zarychanski R, Houston DS. Anemia of chronic disease: a harmful disorder or an adaptive, beneficial response? CMAJ 2008; 179:333-7. [PMID: 18695181 DOI: 10.1503/cmaj.071131] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ryan Zarychanski
- Section of Hematology/Medical Oncology, Department of Internal Medicine, University of Manitoba, Winnipeg, Man
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Abstract
BACKGROUND AND OBJECTIVE The inhibition of thermoregulatory control by anaesthesia is manifested by reduced vasoconstriction and shivering thresholds. As intraoperative bleeding can result in haemodynamic changes, including vasoconstriction, we investigated the effect of experimental bleeding on the shivering threshold in rabbits. METHODS Twenty-four rabbits were randomly assigned to one of three treatment strategies: (1) no blood removal (control), (2) 5 mL kg(-1) isovolaemic blood removal and (3) 10 mL kg(-1) isovolaemic blood removal. After tracheal intubation under isoflurane anaesthesia, anaesthesia was maintained with 50% nitrous oxide in oxygen. The removed blood volume was replaced with the same volume of warm hydroxyethyl starch colloid solution. Oesophageal temperature was measured as a core temperature at 1-min intervals. After blood removal, the animal's body was cooled at a rate of 2-3 degrees C h(-1) by perfusing water at 10 degrees C through a U-shaped thermode positioned in the colon. Hypothermic shivering was evaluated by visual inspection, and the core temperature at which shivering was triggered was identified as the thermoregulatory threshold for this response. RESULTS Just before the cooling, the body temperature of the animals was around 38.6 degrees C in all of the three groups. The shivering threshold in the control group was 37.2 +/- 0.2 degrees C (mean +/- SD). The shivering thresholds in the 5 mL kg(-1) (36.9 degrees +/- 0.3 degrees C) and 10 mL kg(-1) (36.5 degrees +/- 0.5 degrees C) blood removal groups were significantly lower and in proportion with the volume of blood removed than that in the control group. CONCLUSION Isovolaemic haemodilution decreased the shivering threshold in rabbits in proportion with the volume of blood removed.
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Abstract
Inherent risks and increasing costs of allogeneic transfusions underline the socioeconomic relevance of safe and effective alternatives to banked blood. The safety limits of a restrictive transfusion policy are given by a patient's individual tolerance of acute normovolaemic anaemia. latrogenic attempts to increase tolerance of anaemia are helpful in avoiding premature blood transfusions while at the same time maintaining adequate tissue oxygenation. Autologous transfusion techniques include preoperative autologous blood donation (PAD), acute normovolaemic haemodilution (ANH), and intraoperative cell salvage (ICS). The efficacy of PAD and ANH can be augmented by supplemental iron and/or erythropoietin. PAD is only cost-effective when based on a meticulous donation/transfusion plan calculated for the individual patient, and still carries the risk of mistransfusion (clerical error). In contrast, ANH has almost no risks and is more cost-effective. A significant reduction in allogeneic blood transfusions can also be achieved by ICS. Currently, some controversy regarding contraindications of ICS needs to be resolved. Artificial oxygen carriers based on perfluorocarbon (PFC) or haemoglobin (haemoglobin-based oxygen carriers, HBOCs) are attractive alternatives to allogeneic red blood cells. Nevertheless, to date no artificial oxygen carrier is available for routine clinical use, and further studies are needed to show the safety and efficacy of these substances.
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Affiliation(s)
- Andreas Pape
- Clinic of Anoesthesiology, Intensive Care Medicine and Pain Management, J. W. Goethe University Hospital Frankfurt am Main, Theodor Stern Kai 7, 60590 Frankfurt am Main, Germany.
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Habler O, Meier J, Pape A, Kertscho H, Zwissler B. [Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]. Anaesthesist 2007; 55:1142-56. [PMID: 16826416 PMCID: PMC7095856 DOI: 10.1007/s00101-006-1055-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Die zu erwartende Kostensteigerung im Transfusionswesen (steigender Fremdblutbedarf bei gleichzeitig rückläufiger Spendebereitschaft, Behandlungspflicht transfusionsassoziierter Folgeerkrankungen) erhöht den sozioökonomischen Stellenwert der Entwicklung institutionsspezifischer Transfusionsprogramme. Ein wesentlicher Bestandteil hierbei ist – neben einer schonenden Operationstechnik und der konsequenten perioperativen Anwendung fremdblutsparender Maßnahmen – die Ausschöpfung der natürlicherweise vorhandenen „Anämietoleranz“ des menschlichen Organismus (Toleranz größerer Blutverluste durch Verlust von „verdünntem“ Blut, Hinauszögern des Transfusionsbeginns bis nach chirurgischer Blutstillung, Gewinnung von autologem Blut). In der vorliegenden Übersicht werden die Mechanismen, Einflussgrößen und Grenzen dieser natürlichen Anämietoleranz für den Gesamtorganismus und für einzelne Organsysteme zusammengefasst und die sich daraus ergebende Indikation zur Erythrozytentransfusion abgeleitet. Unter kontrollierten Bedingungen (Narkose, strikte Aufrechterhaltung von Normovolämie, komplette Muskelrelaxierung, Hyperoxämie, Hypothermie) werden von kardiopulmonal gesunden Individuen kurzzeitig auch extreme Grade der Verdünnungsanämie [Hämoglobin- (Hb-)Wert <3 g/dl (<1,86 mmol/l)] ohne Transfusion toleriert. In der klinischen Routine bleibt diese Situation – nicht zuletzt in Ermangelung eines adäquaten Monitorings – jedoch auf spezielle Sonderfälle beschränkt (z. B. unerwartete große Blutverluste bei Zeugen Jehovahs, unerwarteter Engpass bei der Bereitstellung von Fremdblut). Die derzeit geltenden Empfehlungen verschiedener Expertenkommissionen decken sich dahingehend, dass perioperativ (1) bis zu einer Hb-Konzentration von 10 g/dl (6,21 mmol/l) auch bei alten Patienten und Patienten mit kardiopulmonalen Begleiterkrankungen eine Transfusion von Erythrozyten in der Regel nicht notwendig ist und (2) eine Transfusion bei jungen, gesunden Patienten ohne kardiopulmonale Vorerkrankungen (einschließlich Schwangeren und Kindern) erst ab einer Hb-Konzentration von <6 g/dl (<3,72 mmol/l) notwendig wird. Auch beatmete Intensivpatienten mit Polytrauma und Sepsis scheinen nicht von einer Transfusion auf Hb-Konzentration >9 g/dl (>5,59 mmol/l) zu profitieren. Bei massiven Blutverlusten und diffuser Blutungsneigung scheint ein Hb von 10 g/dl (6,21 mmol/l) zur Stabilisierung der Blutgerinnung beizutragen.
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Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt am Main.
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Abstract
Every year, about 75 million units of blood are collected worldwide. Red blood cell (RBC) transfusion is one of the few treatments that adequately restore tissue oxygenation when oxygen demand exceeds supply. Although the respiratory function of blood has been studied intensively, the trigger for RBC transfusion remains controversial, and doctors rely primarily on clinical experience. Laboratory assays that indicate failing tissue oxygenation would be ideal to guide the need for transfusion, but none has proved easy, reproducible, and sensitive to regional tissue hypoxia. The clinical importance of the RBCs storage lesion (ie, the time-dependent metabolic, biochemical, and molecular changes that stored blood cells undergo) is poorly understood. RBCs can be filtered, washed, frozen, or irradiated for specific indications. Donor screening and testing have dramatically reduced infectious risks in the developed world, but infection remains a major hazard in developing countries, where 13 million units of blood are not tested for HIV or hepatitis viruses. Pathogen inactivation techniques are in clinical trials for RBCs, but none is available for use. Despite serious immunological and non-immunological complications, RBC transfusion holds a therapeutic index that exceeds that of many common medications.
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Affiliation(s)
- Harvey G Klein
- Department of Transfusion Medicine, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Habler O, Meier J, Pape A, Kertscho H, Zwissler B. [Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]. Urologe A 2007; 46:W543-56; quiz W557-8. [PMID: 17429601 PMCID: PMC7095997 DOI: 10.1007/s00120-007-1344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Die zu erwartende Kostensteigerung im Transfusionswesen erhöht den sozioökonomischen Stellenwert der Entwicklung institutionsspezifischer Transfusionsprogramme. Ein wesentlicher Bestandteil hierbei ist – neben einer schonenden Operationstechnik und der konsequenten perioperativen Anwendung fremdblutsparender Maßnahmen – die Ausschöpfung der natürlichen „Anämietoleranz“ des menschlichen Organismus. Im vorliegenden Beitrag werden die Mechanismen, Einflussgrößen und Grenzen dieser Anämietoleranz für den Gesamtorganismus und für einzelne Organsysteme zusammengefasst und die sich daraus ergebende Indikation zur Erythrozytentransfusion abgeleitet. Die derzeit geltenden Empfehlungen decken sich dahingehend, dass bis zu einer Hämoglobinkonzentration von 10 g/dl (6,21 mmol/l) auch bei alten Patienten oder kardiopulmonalen Begleiterkrankungen eine perioperative Transfusion in der Regel nicht notwendig ist und bei jungen, gesunden Patienten ohne kardiopulmonale Vorerkrankungen (einschließlich Schwangeren und Kindern) erst ab <6 g/dl (<3,72 mmol/l) notwendig wird. Auch beatmete Intensivpatienten mit Polytrauma und Sepsis scheinen nicht von einer Transfusion auf eine Hämoglobinkonzentration >9 g/dl (>5,59 mmol/l) zu profitieren. Bei massiven Blutverlusten und diffuser Blutungsneigung scheint ein Wert von 10 g/dl (6,21 mmol/l) zur Stabilisierung der Blutgerinnung beizutragen.
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Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt a.M.
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Haskins SC. Comparative cardiovascular and pulmonary effects of sedatives and anesthetic agents and anesthetic drug selection for the trauma patient. J Vet Emerg Crit Care (San Antonio) 2006. [DOI: 10.1111/j.1476-4431.2006.00188.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rat or human-based blood therapy in acute myocardial infarction? Crit Care Med 2006. [DOI: 10.1097/01.ccm.0000226402.68391.d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pape A, Meier J, Kertscho H, Steche M, Laout M, Schwerdel F, Wedel M, Zwissler B, Habler O. Hyperoxic ventilation increases the tolerance of acute normovolemic anemia in anesthetized pigs. Crit Care Med 2006; 34:1475-82. [PMID: 16540965 DOI: 10.1097/01.ccm.0000215826.45839.36] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the impact of prophylactic hyperoxic ventilation with Fio2 0.6 on the physiologic limit of acute normovolemic anemia. DESIGN Prospective, controlled, randomized experimental study. SETTING Experimental animal laboratory of a university hospital. SUBJECTS Fourteen anesthetized domestic pigs. INTERVENTIONS Animals were randomly ventilated with either Fio2 0.21 (group 0.21, n = 7) or Fio2 0.6 (group 0.6, n = 7), and acute anemia was induced by isovolemic blood-for-hydroxy-ethylstarch (HES) exchange using a 6% HES solution (130/0.4). MEASUREMENTS AND MAIN RESULTS The blood-for-HES-exchange was continued until a sudden decrease of total body oxygen consumption indicated the onset of oxygen supply dependency (primary end point); the corresponding hemoglobin (Hb) concentration was defined as "critical" (Hb(crit)). Secondary end points were changes in myocardial function, central hemodynamics, oxygen transport, and tissue oxygenation. Compared with room air ventilation (Fio2 0.21), hyperoxic ventilation with Fio2 0.6 enabled a larger blood-for-HES-exchange (139%, 124/156) of circulating blood volume vs. 87% (68/94, p < .05), until Hb(crit) was reached (1.5 g/dL [1.4/2.1] vs. 2.4 g/dL [2.0/2.8], p < .05). At Hb 2.4 g/dL (i.e., Hb(crit) in group 0.21), animals of group 0.6 still presented with superior oxygen transport, tissue oxygenation, and hemodynamic stability. However, hemodynamic and oxygen transport variables were found deteriorated more severely at Hb 1.5 g/dL (i.e., Hb(crit) of group 0.6) compared with group 0.21 at Hb 2.4 g/dL. CONCLUSION During cell-free volume replacement, hyperoxic ventilation with Fio2 0.6 generates a readily usable plasmatic oxygen reserve and thereby increases the tolerance toward acute normovolemic anemia.
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Affiliation(s)
- A Pape
- Johann Wolfgang Goethe-University, Frankfurt/Main, Germany
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Fraga ADO, Fantoni DT, Otsuki DA, Pasqualucci CA, Abduch MCD, Junior JOCA. EVIDENCE FOR MYOCARDIAL DEFECTS UNDER EXTREME ACUTE NORMOVOLEMIC HEMODILUTION WITH HYDROXYETHYL STARCH AND LACTATED RINGER'S SOLUTION. Shock 2005; 24:388-95. [PMID: 16205326 DOI: 10.1097/01.shk.0000180617.21564.b3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute normovolemic hemodilution (ANH) has been proposed to avoid the risks of allogenic transfusion. In reference to its cellular effects, ANH reports in the literature are scarce. Using electron microscopy (EM), we evaluated the effects of ANH on cardiac function and myocardial structure. Twenty-five dogs were prospectively randomized to a control group (n = 5) or to undergo ANH with 6% hydroxyethyl starch (HES; n = 10) or lactated Ringer's solution (LR; n = 10) administered, respectively, at a ratio of 1:1 or 1:3 to the volume of blood removed. Animals were gradually hemodiluted to a hematocrit of 10%, which was accomplished in 80 min. Pulmonary artery catheter and echocardiography were used to evaluate cardiac function. Myocardial samples were taken after the last time point for electron microscopy analysis. Data were obtained during five different stages of ANH, with a mean 20-min interval between each time point. Cardiac index increased significantly in both groups during ANH. A significant decrease in oxygen delivery and oxygen consumption, as well as an increase in oxygen extraction was verified in the LR group. Echocardiography demonstrated a decline in systolic function in the LR group at the end of the experiment. Electron microscopy analysis of the myocardium revealed slight lesions in cardiac cells in the HES group, and moderate-to-significant lesions in the LR group. In this animal species, ANH with HES resulted in better preservation of cardiac function, which was demonstrated by maintenance of systolic function and oxygenation parameters. Minor loss of cellular integrity with HES, in the presence of very low levels of hemoglobin, reinforces these findings.
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Affiliation(s)
- Adilson de Oliveira Fraga
- Department of Anesthesia, Heart Institute (Incor)-Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
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Pearce FJ, Waasdorp C, Hufnagel H, Burris D, DeFeo J, Soballe P, Drucker WR. Subcutaneous Po2 as an index of the physiological limits for hemodilution in the rat. J Appl Physiol (1985) 2005; 99:814-21. [PMID: 15890752 DOI: 10.1152/japplphysiol.00816.2003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study was designed to test the hypothesis that changes in subcutaneous Po2 (PscO2) during progressive hemodilution will reliably predict a “critical point” at which tissue O2 consumption (V̇o2) becomes dependent on O2 delivery (Q̇o2). Twelve pentobarbital-anesthetized male Sprague-Dawley rats (315–375 g) underwent stepwise exchange of plasma for blood (1.5 ml of plasma for each 1 ml of blood lost). The initial exchange was equal to 25% of the estimated circulatory blood volume, and each subsequent exchange was equal to 10% of the estimated circulatory blood volume. After nine exchanges, the hematocrit (Hct) fell from 42 ± 1 to 6 ± 1%. Cardiac output and O2 extraction rose significantly. PscO2 became significantly reduced ( P < 0.05) after exchange of 45% of the blood volume (Hct = 16 ± 1%). V̇o2 became delivery dependent when Q̇o2 fell below 21 ml·min−1·kg body wt−1 (mean Hct = 13 ± 1%). Eight control rats undergoing 1:1 blood-blood exchange showed no change in PscO2, pH, HCO3−, or hemodynamics. Measurement of PscO2 may be a useful guide to monitor the adequacy of Q̇o2 during hemodilution.
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Affiliation(s)
- Frederick J Pearce
- Walter Reed Army Institute of Research, Dept. of Resuscitative Medicine, Rm. 1A34, 503 Robert Grant Ave., Silver Spring, MD 20910, USA.
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Affiliation(s)
- Aryeh Shander
- Mount Sinai School of Medicine, Mount Sinai Hospital, New York, New York, USA.
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Jamnicki M, Kocian R, van der Linden P, Zaugg M, Spahn DR. Acute normovolemic hemodilution: physiology, limitations, and clinical use. J Cardiothorac Vasc Anesth 2003; 17:747-54. [PMID: 14689419 DOI: 10.1053/j.jvca.2003.09.018] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Marina Jamnicki
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
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