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The effects of acute normovolemic hemodilution on coagulation and blood utilization in major surgery
JOURNAL
OF SURGICAL
RESEARCH
The Effects Coagulation HILLEL
LAKS,
20, 2255230 (1976)
of Acute
Normovolemic
and Blood
M.B.B.CH.,~
Utilization
ROBERT AND
I. HANDIN,
ROBERT
N.
PILON,
Hemodilution in Major M.D.,3
on
Surgery’
VERA
MARTIN,
B.S.,
M.D.
Department of Surgery, Department ofAnesthesia, and Division OfHematology, Department of Medicine, Peter Bent Brigham Hospital, and Harvard Medical School, Boston, Massachusetts 02115 Submitted for publication December 1, 1975
There have been several studies on the effects of hemorrhage and massive transfusion on coagulation in man [l, 2, 11, 19, 21, 301. Interpretation of these studies is difficult since the observed changes in coagulation may have been caused by hemodilution alone or by the presence of hypovolemic or septic shock. There have been several studies demonstrating coagulation changes consistent with disseminated intravascular coagulation (DIC) in dogs with hypovolemic shock [5, 12, 171.Herman et al., induced hypovolemic shock in baboons and did not observe any effect on coagulation until volume repletion with salt solutions [IO]. They concluded that the observed changes reflected hemodilution rather than DIC. Intraoperative prebleeding with hemodilution has been practiced clinically both in cardiac [6, 18, 231 and general surgery [14, 16,281. At the Peter Bent Brigham Hospital, it has been used in major surgery to avoid the adverse effects of homologous blood utilization and to conserve blood. Since this procedure dilutes plasma proteins and could alter coagulation, the effects of acute normovolemic hemodilution on hemostasis were studied in nine patients, and the blood utiliza‘Supported by Nehemias Gorin Foundation, Grant No. HL-17513-01, and by agrant from the Research Division, United States Army Research and Development Command, No. DADA 17-173-C-3022. %urrent address: Department of Surgery, St. Louis University, 1325 S. Grand Blvd., St. Louis, MO. 63104. 3Dr. Handin is a Cancer Research Scholar, Massachusetts Division, American Cancer Society.
tion of 19 patients undergoing major surgery with hemodilution was reviewed. MATERIALS AND METHODS Nineteen patients, age 25-69 yr, underwent intraoperative prebleeding with acute normovolemic hemodilution. Eleven underwent total hip replacement, six aortoiliac reconstructive surgery, one a forequarter amputation, and one an abdominoperineal resection. Patients with cardiac renal or pulmonary disease were excluded. Four were Jehovah’s Witnesses who agreed to hemodilution with lactated Ringer’s solution, and two had difficulties with cross matching. Anesthesia was induced with thiopental (Pentothal) and maintained with nitrous oxide and fluoroxene. Blood pressure was monitored by a radial artery cannula and pulmonary artery pressure by a Swan-Ganz catheter. Hemodilution was conducted under anesthesia while preparations for surgery were in progress, as previously described [15, 161.Blood was drained from a large-bore venous cannula inserted in the external jugular vein and if necessary from the radial artery cannula. The blood was collected in plastic bags (Fenwal) containing 63 ml of citrate-phosphatedextrose solution, and the hemodiluting agent was infused simultaneously. The mean volume bled was 1640 ml. In eight patients Plasmanate in a volume equal to that of the 4Plasmanate (Cutter Laboratories, Berkeley, Calif.) contains 5% protein, mainly albumin, in 0.15 M concentration of saline.
225 Copyright o 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
226
JOURNAL
OF SURGICAL
RESEARCH:
shed blood and an equal volume of lactated Ringer’s solution was used for hemodilution. In I I patients lactated Ringer’s solution in a volume 2.7 times that of the shed blood was used. In I5 patients hemodilution was conducted in one stage over 15 to 30 min, while in four patients, hemodilution was conducted in two stages, each lasting 20 min. During the initial part of the operative procedure, blood loss was replaced by the hemodiluting agent, and towards the end of the operation the pre-bled blood was reinfused. In the postoperative period, homologous blood was given as necessary to maintain the hematocrit at about 30%. Nine patients were studied to evaluate the effects of hemodilution on coagulation. Seven underwent total hip replacement, one aortoiliac reconstruction, and one an abdominoperineal resection. The patients were anesthetized with thiopental (Pentothal) for induction and fluoroxene and nitrous oxide for maintenance. In six patients (Group I) after induction of anesthesia, 40% of the estimated blood volume was removed over 20 min and replaced simultaneously with a volume of Plasmanate equal to that of the shed blood and an equal volume of lactated Ringer’s solution. The mean volume of blood removed was 1618 ml. One patient received only lactated Ringer’s solution in a volume three times that of the pre-bled blood. Blood for coagulation studies was drawn just prior to hemodilution, immediately following hemodilution, 30 min later, and at the end of operation. In three patients (Group II) undergoing total hip replacement, hemodilution was performed in two stages. Initially 25% of the estimated blood volume, a mean of 1066 ml, was withdrawn over 20 min (Hemodilution I) with simultaneous replacement of the hemodiluting solutions. These consisted of a volume of Plasmanate equal to that of the shed blood and an equal volume of lactated Ringer’s solution. Approximately 45 min later, Hemodilution II was conducted in an identical manner with a mean of 1066 ml of blood withdrawn over 20 min. Blood samples
VOL. 20, NO. 3, MARCH
1976
were taken before Hemodilution I and after Hemodilution II. The blood collected in the citrate-phosphate-dextrose anticoagulant from the radial artery and external jugular vein, was returned to the patient toward the end of the operation. Additional homologous blood was given if indicated. Large-vessel hematocrit was measured in triplicate on heparinized blood [31]. Blood for coagulation studies was collected in 0.38% sodium citrate. Platelet-rich plasma was prepared by centrifugation at 5OOgfor 10 min and platelet-poor plasma by additional centrifugation at 1OOOg for 10 min. Platelet-poor plasma for coagulation studies was stored at -20°C until the time of the study. The prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen level were measured by standard techniques [25, 26, 271.Platelets were counted by phase contrast microscopy (4). The modified Ivy bleeding time was performed using plastic tenplates [20]. Factors II, V and the VII-X complex were measured by one-stage techniques, using artificially prepared substrate plasma [24]. Platelet aggregation in responseto standard dosesof adenosinedisphosphate (ADP), epinephrine, and collagen was measured as previously described [7]. RESULTS Blood utilization. In the 19 patients whose clinical course was reviewed, the mean volume bled was 1640ml. The hematocrit fell from a mean of 42% preoperatively to 22% immediately after operation. Homologous blood utilization during the operative procedure was 0.3 units. Postoperatively, a mean of 1.2 units was given. The mean hematocrit at the time of discharge was 33%. All patients received oral iron therapy in the postoperative course. One patient developed a wound hematoma after total hip replacement. There were no wound infections. Two patients after total hip replacement had a transient period of confusion. Hemodilution resulted in a diuresis both intraoperatively and postoperatively. Mild generalized edema
LAKS ET AL.: NORMOVOLEMIC
HEMODILUTION
AND HEMOSTASIS
227
TABLE 1 Effects of Hemodilution on Coagulation in Group I PTT (set) (Pt/control)
Fibrinogen (mg %I
Platelet (103/mm3)
Bleeding time (min)
Hematocrit (%)
4.50 4.00 5.00 -
41.0 40.5 48.5 47.0 41.6 37.0 42.6 1.77
Patient
PT (set) (Pt/control)
Baseline 1 2 3 4 5 6 Mean f SEM
12.8/10.8 10.5/10.8 12.8/11.8 12.0/11.0 11.8/10.9 11.3/10.8 11.87/11.02 0.36/0.16
22.0131.9 19.4128.4 25.83129.2 2.38/1.50
440 288 468 343.3 45.21
Immediate post-hemodilution 1 13.3/10.8 2 13.3/10.8 4 13.3/11.0 5 13.4/10.9 6 13.8/10.8 Mean 13.4/10.9 f SEM 0.10/0.04
51.9/29.3 31.5129.8 69.0/35.0 27.4131.9 39.0128.4 43.8130.9 7.56/1.18
276 180 264 108 264 218.4 32.5
125 250 160 252 200
20.5/10.8 42.7129.8 24.8122.5 31.3122.5
204
116 235 205 180 165 250
11.5 -
191.8
10.8 0.65
30 Min post-hemodilution 1 13.3/10.8 2 11.8/10.8 3 15.3/11.8 4 12.9/11.0 5 14.3/10.9 6 12.8/10.8 Mean 13.4/11.0 f SEM 0.50/0.16 - End of operation 1 12.4/10.8 2 3 4 5 6
14.7/10.8 13.3/11.8 12.3/11.0
14.2/10.9 13.8/10.8
Mean i SEM
13.5/11.0 0.36/0.16
25.5129.3 28.3129.8 23.8122.5 36.0133.0
30.5/31.9 36.7128.4 31.1124.3 3.2613.13
16.3129.3 40.1/29.8 22.3122.5 22.8132.5 32.1126.9 35.7128.4 28.2128.2 3.7411.37
264 408
192
192 72 276 48 324 186 44.5 264 144 132 312 60 240
192 38.8
138 362 200 145 350 300 249.2 41.28
197.4 24.9
20 120 240 172 132 105 155 154
19.8
5.00 3.25 4.35 0.33 6.00 23.25 30.00 2.00 15.3 6.7
10.2
-
7.50 24.74 4.20 7.00 5.35 9.75 3.8
29.0 24.0 26.5 22.6 27.0 25.82 1.13 29.0 24.3 28.2 27.0 23.0 27.2 26.5 0.95 29.0 28.0 30.0 36.0 30.0 31.0 31.3 2.40
cleared over 24 hr and was more marked in time increased slightly following hemodiluthe group hemodiluted with lactated Ringer’s tion and remained prolonged until the end of solution. the operation. There was a greater increase Coagulation studies. Phlebotomy and fluid in the partial thromboplastin time following replacement lowered the hematocrit from 43 hemodilution which gradually returned to 25% in group I (Table 1 Fig. 1) and to 22% toward normal. in group II (Table 2). There was also a 40% There were changes in individual coagulafall in the level of fibrinogen and a 25% tion proteins associated with the increase in decrease in platelet count immediately fol- prothrombin time and partial thromboplastin lowing hemodilution, which persisted time as shown in Tables 1 and 2. In two throughout the operation. The prothrombin patients the measured level of Factor II (pro-
JOURNAL OF SURGICAL
228
RESEARCH: VOL. 20, NO. 3, MARCH 1976
Bleeding time. The mean bleeding time prior to hemodilution was 4.4 =t 0.3 min (mean + SEM). Immediately following hemodilution, the bleeding time had increased to 15.3 i 6.7 min and remained prolonged throughout the operation (Table 1). Platelet aggregation. In view of the prolonged bleeding time, platelet aggregation was measured in three patients. Following hemodilution, aggregation with collagen, ADP, and epinephrine was normal in all three patients. In two patients, secondary aggregation with epinephrine was absent and aggregation with collagen and ADP reduced at the end of the operative procedure.
9oL.. FIG. 1. The relationship of the changesin coagulation parameters to hemodilution. All are expressed as a percentage of baseline. Prothombin time (PT) and partial thromboplastin time (PTT) were calculated from control over patient’s values and then expressed as a percentage of baseline.
thrombin) decreased immediately after hemodilution from control values of 140 and 175 mg% to 66 and 112 mg% but had returned to normal at the end of the operation. There was no change in the level of Factor V, while the level of the VII-X complex was 120 and 145 mg% and fell slightly at the end of operation to 88 and 110 mg%, respectively.
DISCUSSION Review of the clinical course of these patients showed that hemodilution effectively reduced the utilization of homologous blood without significant complications. The hemodynamic effects of hemodilution have been previously reported [14, 151. Although careful measurement of blood loss was not undertaken, it seems clear that the utilization of a mean of 1.5 units of blood for these major surgical procedures indicates significant blood conservation. The data presented here document changes in the level of several coagulation factors and in the overall rate of coagulation as measured by the prothrombin time and
TABLE 2 Effects of Hemodilution on Coagulation in Group II PTT (set) (Pt/control)
Patient
PT (set) (Pt/control)
Baseline 7 8 9 Mean f SEM
12.5/11.5 12.0112.4 11.9/11.9 12.1/11.9 0.19/O.26
24.3127.8 33.0/31.0 25.6/30.0 27.6129.6 2.7110.95
30 Min post-hemodilution 7 15.0/11.5 156112.4 8 14.3/11.9 9 Mean 15.0/11.9 f SEM 0.38/0.26
67.3127.8 60.9/31.0 28.0/30.0 52.1129.6 12.17/0.95
Platelet (10s/mm3)
Hematocrit (%)
480 252 408 380 67
240.0 680.0 302.5 407.5 137.5
39 44 48 43.6 2.60
276 60 180 172 62
175.0 55.0 267.5 166.0 61.5
23 20 23 22 1.00
Fibrinogen (mg %)
LAKS
ET AL.: NORMOVOLEMIC
HEMODILUTION
partial thromboplastin time following acute normovolemic hemodilution. There were also changes in platelet number and in platelet function, as measured by the bleeding time and platelet aggregation studies. Although the platelet count fell significantly following hemodilution, the levels reached were at no time in the range usually associated with clinical bleeding [8]. The observed mean platelet counts paralleled the fall in hematocrit, as outlined in Fig. 1. The actual platelet counts were slightly higher than that predicted from the change in hematocrit, which may be explained by release of immature platelets from bone marrow and splenic pools stimulated by the acute change in hematocrit [13, 291. Other studies of platelet count following massive transfusion for bleeding have shown that the platelet count will fall to lOO,000/mm3 after 12 units of blood have been administered [ 131.Herman et al., in a study of coagulation changes in hemorrhagic shock induced in baboons also found that the fall in platelet count was proportional to the fall in hematocrit [lo]. McNamara [19] and Miller [21], who studied coagulation defects associated with massive transfusion in man, also found the reduction in platelet count to parallel the extent of hemodilution. In addition to the decrease in the number of circulating platelets, there was a fall in the level of fibrinogen, prothrombin and Factors VII-X. These changes could also be caused by simple hemodilution. Although these decreases might account for the transient prolongation of the PT and PTT, the levels were still in the range necessary for normal hemostasis [3]. The prolonged bleeding time observed immediately after hemodilution was of considerable interest. While all the patients were thrombocytopenic, the decrease was not low enough to account for the increased bleeding time [8]. Simultaneous platelet aggregation studies were normal in all three patients following hemodilution. However, two patients had abnormal aggregation when measured at the end of their operation. This
AND
HEMOSTASIS
229
was not associated with any further increase in bleeding time. O’Brien has reported similar changes following surgery and has postulated that they are due to release of small amounts of ADP from traumatized tissue and platelets [22]. None of these patients had excess bleeding noted during surgery. Hemodilution also reduces blood viscosity and increases blood flow to skeletal muscle and skin [16]. Clinically, it was apparent that these patients had extremely warm skin, although their central body temperature was often reduced by one or two degrees. This increase in skin temperature was thought to be due to an increase in cutaneous blood flow. The marked elevation in the bleeding time might be related to this increased blood flow in cutaneous vessels rather than to an abnormality in platelet function [9]. Our study shows that phlebotomy and replacement with colloid and crystalloid solutions results in a fall in platelet count, dilution of plasma coagulation proteins, and a prolongation of the bleeding time. Most of the studies return to normal at the end of operation, following reinfusion of the patient’s freshly drawn blood. In the patient studies, there was no evidence of any increased bleeding during the procedure. Specifically, the large volume of Plasmanate infused did not appear to induce any coagulation abnormality. On the basis of these studies, we feel that acute normovolemic hemodilution associated with reinfusion of autologous blood may be a safe, effective means to support selected patients for elective surgical procedures involving major blood loss. ACKNOWLEDGMENTS authorswould like to thank Drs. F. D.
The L. Van Dam for advice and encouragement ing this work.
Moore and in complet-
REFERENCES 1.
Alter, S., Kirby, S. W., Jr., Masaitis, C., Alonsberger, A. R., Jr., and Crowley, R. A. Coagulationchanges in clinicalshock. Ann. Surg. 164:34, 1966.
230
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RESEARCH:
2. Attar, S., Boyd, D., Cayse, E., McLaughlin, J., Monsberger, A. R., and Romley, R. A. Alterations in coagulation and fibrinolytic mechanisms in acute trauma. J. Trauma9:939, 1969. 3. Ayseler, P. M. Physiologic basis for transfusion therapy in hemorrhagic disorder. Transfusion 1:71, 1961. 4. Brecker, G., and Cronkite, E. P. Morphology and enumeration of human blood platelets. J. Appl. Physiol. 3:365, 1950. 5. Broersma, R. J., Bullener, G. D., and Mammen, E. F. Blood coagulation changes in hemorrhagic shock and acidosis. Thromb. Diaih. Haemorrh. Suppl. 36:171, 1969. 6. Hallowell, P., er a/. The reduction of banked blood requirements by fresh autologous blood transfusion in open heart surgery. Abstracts. Amer. Sot. Anesthesiol., Annual Meeting, Boston, 1972. 7. Handin, R. I., and Valeri, C. R. Hemostatic effectiveness of platelets stored at 22°C. N. Engl. J. Med. 285:538, 1972. 8. Harker, L. S., and Slichter, S. J. The bleeding time as a screening test for evaluation of platelet function. N. Engl. J. Med. 281:155, 1972. 9. Hellem, A., Borchgrevine, C. F., and Ares, S. B. The role of red cells in hemostasis: The relation between hematocrit, bleeding time and platelet adhesiveness. Brit. J. Haematol. 7:42, 1961. 10. Herman, C. M., Moquin, R. R., and Horwitz, D. L. Coagulation changes of hemorrhagic shock in baboons. Ann. Surg. 175:197,1972. 11. Innes, D., and Sevitt, S. Coagulation and fibrinolysis in injured patients. J. Clin. Parhol. 17:1, 1964. 12. Irani, B. B., and Clifton, E. E. Coagulation and metabolic changes during hemorrhagic shock. Angiology 21:161, 1970. 13. Krevens, J. R., and Jackson, D. P. Hemorrhagic disorder following massive whole blood transfusions. J. Amer. Med. Assoc. 59:171, 1955. 14. Laks, H., Pilon, R. N., Anderson, W., MacCallum, J. R., and O’Connor, N. E. Intraoperative prebleeding in man: Effect of colloid hemodilution on blood volume, lung water, hemodynamics, and oxygen transport. Surgery 78:130, 1975. 15. Laks, H., Pilon, R. N., Anderson, W., and &Connor, N. E. Acute normovolemic hemodilution with crystalloid vs. colloid replacement. Surg. Forum 25:21, 1974. 16. Laks, H., Pilon, R. N., Klovekorn, W. P., Anderson, W., MacCallum, J. R., and O’Connor, N. E.: Acute hemodilution: Its effect on hemodynamics and
VOL. 20, NO. 3, MARCH
1976
oxygen transport in anesthetized man. Ann. Surg. 180:103,1974. 17. Lasch, J. G. Coagulation disturbances in shock. Postgrad. Med. J. 45~539, 1969. 18. Laver, M. B., and Buckley, M. J. Extreme hemodilution in the surgical patient. In K. Messmen and H. Schmid-Schoenbein (Eds.), Hemodilution: Theoretical Basis and Clinical Application, Prof. Int. Symp., Rottach-Egern, 1971, p. 215. Karger, Basel, 1972. 19. McNamara, J. J., Burran, E. L., Stremple, J. F., and Molot, M. D. Coagulopathy after major combat injury: Occurrence, management and pathophysiology. Ann. Surg. 176:243, 1972. 20. Mielke, C. H., Jr., Kaneshiro, M. M., Maher, I. A., Weiner, J. M., and Rapaport, S. 1. The standardized normal ivy bleeding and its prolongation by aspirin. Blood 34:204, 1969. 21. Miller, R. D., Robbins, R. O., Tong, M. J., and Varton, S. R. Coagulation defects associated with massive blood transfusions. Ann. Surg. 174:794, 1971. 22. O’Brien, J. R., Etherington, M., and Jamieson, S. Major operations. Lancer 2:741, 197 1. 23. Ochsner, J. L., et al. Fresh autologous blood transfusions with extracorporeal circulation. Ann. Surg. 177:811, 1973. 24. Owen, C. A., Bowie, E. J. W., Didisheim, P., and Thompson, J. H., Jr. The Diagnosis of Bleeding Disorders, p. 105. Little, Brown, Boston, 1969. 25. Proctor, R. R., and Rapaport, S. I. The partial thromboplastin time with kaolin. Amer. J. Clin. Pathol. 36:212, 1961. 26. Quick, A. J. Determination of prothrombin. Amer. J. Med. Sci. 190:501, 1935. 27. RatnolT, O., and Menzie, C. Determination of plasma fibrinogen. J. Lab. Clin. Med. 37:316, 1951. 28. Rush, B. F., et al. Limitations of blood replacement with electrolyte solutions. Arch. Surg. 98:49, 1969. 29. Shulman, N. R., Watkins, S. P., Itscoitz, S. B., and Students, A. R. Evidence that the spleen retains the youngest and hemostatically most effective platelets. Trans. Amer. Assoc. Physicians 81:302, 1968. 30. Simmons, R. C., Collins, J. A., Heisterkamp, C. A., Mills, D. E., Andrew, R., and Phillips, L. L. Coagulation disorders in combat casualties. Ann. Surg. 169:455, 1969. 31. Wintrobe, M. M. Anemia. Arch. Intern. Med. 54:256, 1934.
OF SURGICAL
RESEARCH
The Effects Coagulation HILLEL
LAKS,
20, 2255230 (1976)
of Acute
Normovolemic
and Blood
M.B.B.CH.,~
Utilization
ROBERT AND
I. HANDIN,
ROBERT
N.
PILON,
Hemodilution in Major M.D.,3
on
Surgery’
VERA
MARTIN,
B.S.,
M.D.
Department of Surgery, Department ofAnesthesia, and Division OfHematology, Department of Medicine, Peter Bent Brigham Hospital, and Harvard Medical School, Boston, Massachusetts 02115 Submitted for publication December 1, 1975
There have been several studies on the effects of hemorrhage and massive transfusion on coagulation in man [l, 2, 11, 19, 21, 301. Interpretation of these studies is difficult since the observed changes in coagulation may have been caused by hemodilution alone or by the presence of hypovolemic or septic shock. There have been several studies demonstrating coagulation changes consistent with disseminated intravascular coagulation (DIC) in dogs with hypovolemic shock [5, 12, 171.Herman et al., induced hypovolemic shock in baboons and did not observe any effect on coagulation until volume repletion with salt solutions [IO]. They concluded that the observed changes reflected hemodilution rather than DIC. Intraoperative prebleeding with hemodilution has been practiced clinically both in cardiac [6, 18, 231 and general surgery [14, 16,281. At the Peter Bent Brigham Hospital, it has been used in major surgery to avoid the adverse effects of homologous blood utilization and to conserve blood. Since this procedure dilutes plasma proteins and could alter coagulation, the effects of acute normovolemic hemodilution on hemostasis were studied in nine patients, and the blood utiliza‘Supported by Nehemias Gorin Foundation, Grant No. HL-17513-01, and by agrant from the Research Division, United States Army Research and Development Command, No. DADA 17-173-C-3022. %urrent address: Department of Surgery, St. Louis University, 1325 S. Grand Blvd., St. Louis, MO. 63104. 3Dr. Handin is a Cancer Research Scholar, Massachusetts Division, American Cancer Society.
tion of 19 patients undergoing major surgery with hemodilution was reviewed. MATERIALS AND METHODS Nineteen patients, age 25-69 yr, underwent intraoperative prebleeding with acute normovolemic hemodilution. Eleven underwent total hip replacement, six aortoiliac reconstructive surgery, one a forequarter amputation, and one an abdominoperineal resection. Patients with cardiac renal or pulmonary disease were excluded. Four were Jehovah’s Witnesses who agreed to hemodilution with lactated Ringer’s solution, and two had difficulties with cross matching. Anesthesia was induced with thiopental (Pentothal) and maintained with nitrous oxide and fluoroxene. Blood pressure was monitored by a radial artery cannula and pulmonary artery pressure by a Swan-Ganz catheter. Hemodilution was conducted under anesthesia while preparations for surgery were in progress, as previously described [15, 161.Blood was drained from a large-bore venous cannula inserted in the external jugular vein and if necessary from the radial artery cannula. The blood was collected in plastic bags (Fenwal) containing 63 ml of citrate-phosphatedextrose solution, and the hemodiluting agent was infused simultaneously. The mean volume bled was 1640 ml. In eight patients Plasmanate in a volume equal to that of the 4Plasmanate (Cutter Laboratories, Berkeley, Calif.) contains 5% protein, mainly albumin, in 0.15 M concentration of saline.
225 Copyright o 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
226
JOURNAL
OF SURGICAL
RESEARCH:
shed blood and an equal volume of lactated Ringer’s solution was used for hemodilution. In I I patients lactated Ringer’s solution in a volume 2.7 times that of the shed blood was used. In I5 patients hemodilution was conducted in one stage over 15 to 30 min, while in four patients, hemodilution was conducted in two stages, each lasting 20 min. During the initial part of the operative procedure, blood loss was replaced by the hemodiluting agent, and towards the end of the operation the pre-bled blood was reinfused. In the postoperative period, homologous blood was given as necessary to maintain the hematocrit at about 30%. Nine patients were studied to evaluate the effects of hemodilution on coagulation. Seven underwent total hip replacement, one aortoiliac reconstruction, and one an abdominoperineal resection. The patients were anesthetized with thiopental (Pentothal) for induction and fluoroxene and nitrous oxide for maintenance. In six patients (Group I) after induction of anesthesia, 40% of the estimated blood volume was removed over 20 min and replaced simultaneously with a volume of Plasmanate equal to that of the shed blood and an equal volume of lactated Ringer’s solution. The mean volume of blood removed was 1618 ml. One patient received only lactated Ringer’s solution in a volume three times that of the pre-bled blood. Blood for coagulation studies was drawn just prior to hemodilution, immediately following hemodilution, 30 min later, and at the end of operation. In three patients (Group II) undergoing total hip replacement, hemodilution was performed in two stages. Initially 25% of the estimated blood volume, a mean of 1066 ml, was withdrawn over 20 min (Hemodilution I) with simultaneous replacement of the hemodiluting solutions. These consisted of a volume of Plasmanate equal to that of the shed blood and an equal volume of lactated Ringer’s solution. Approximately 45 min later, Hemodilution II was conducted in an identical manner with a mean of 1066 ml of blood withdrawn over 20 min. Blood samples
VOL. 20, NO. 3, MARCH
1976
were taken before Hemodilution I and after Hemodilution II. The blood collected in the citrate-phosphate-dextrose anticoagulant from the radial artery and external jugular vein, was returned to the patient toward the end of the operation. Additional homologous blood was given if indicated. Large-vessel hematocrit was measured in triplicate on heparinized blood [31]. Blood for coagulation studies was collected in 0.38% sodium citrate. Platelet-rich plasma was prepared by centrifugation at 5OOgfor 10 min and platelet-poor plasma by additional centrifugation at 1OOOg for 10 min. Platelet-poor plasma for coagulation studies was stored at -20°C until the time of the study. The prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen level were measured by standard techniques [25, 26, 271.Platelets were counted by phase contrast microscopy (4). The modified Ivy bleeding time was performed using plastic tenplates [20]. Factors II, V and the VII-X complex were measured by one-stage techniques, using artificially prepared substrate plasma [24]. Platelet aggregation in responseto standard dosesof adenosinedisphosphate (ADP), epinephrine, and collagen was measured as previously described [7]. RESULTS Blood utilization. In the 19 patients whose clinical course was reviewed, the mean volume bled was 1640ml. The hematocrit fell from a mean of 42% preoperatively to 22% immediately after operation. Homologous blood utilization during the operative procedure was 0.3 units. Postoperatively, a mean of 1.2 units was given. The mean hematocrit at the time of discharge was 33%. All patients received oral iron therapy in the postoperative course. One patient developed a wound hematoma after total hip replacement. There were no wound infections. Two patients after total hip replacement had a transient period of confusion. Hemodilution resulted in a diuresis both intraoperatively and postoperatively. Mild generalized edema
LAKS ET AL.: NORMOVOLEMIC
HEMODILUTION
AND HEMOSTASIS
227
TABLE 1 Effects of Hemodilution on Coagulation in Group I PTT (set) (Pt/control)
Fibrinogen (mg %I
Platelet (103/mm3)
Bleeding time (min)
Hematocrit (%)
4.50 4.00 5.00 -
41.0 40.5 48.5 47.0 41.6 37.0 42.6 1.77
Patient
PT (set) (Pt/control)
Baseline 1 2 3 4 5 6 Mean f SEM
12.8/10.8 10.5/10.8 12.8/11.8 12.0/11.0 11.8/10.9 11.3/10.8 11.87/11.02 0.36/0.16
22.0131.9 19.4128.4 25.83129.2 2.38/1.50
440 288 468 343.3 45.21
Immediate post-hemodilution 1 13.3/10.8 2 13.3/10.8 4 13.3/11.0 5 13.4/10.9 6 13.8/10.8 Mean 13.4/10.9 f SEM 0.10/0.04
51.9/29.3 31.5129.8 69.0/35.0 27.4131.9 39.0128.4 43.8130.9 7.56/1.18
276 180 264 108 264 218.4 32.5
125 250 160 252 200
20.5/10.8 42.7129.8 24.8122.5 31.3122.5
204
116 235 205 180 165 250
11.5 -
191.8
10.8 0.65
30 Min post-hemodilution 1 13.3/10.8 2 11.8/10.8 3 15.3/11.8 4 12.9/11.0 5 14.3/10.9 6 12.8/10.8 Mean 13.4/11.0 f SEM 0.50/0.16 - End of operation 1 12.4/10.8 2 3 4 5 6
14.7/10.8 13.3/11.8 12.3/11.0
14.2/10.9 13.8/10.8
Mean i SEM
13.5/11.0 0.36/0.16
25.5129.3 28.3129.8 23.8122.5 36.0133.0
30.5/31.9 36.7128.4 31.1124.3 3.2613.13
16.3129.3 40.1/29.8 22.3122.5 22.8132.5 32.1126.9 35.7128.4 28.2128.2 3.7411.37
264 408
192
192 72 276 48 324 186 44.5 264 144 132 312 60 240
192 38.8
138 362 200 145 350 300 249.2 41.28
197.4 24.9
20 120 240 172 132 105 155 154
19.8
5.00 3.25 4.35 0.33 6.00 23.25 30.00 2.00 15.3 6.7
10.2
-
7.50 24.74 4.20 7.00 5.35 9.75 3.8
29.0 24.0 26.5 22.6 27.0 25.82 1.13 29.0 24.3 28.2 27.0 23.0 27.2 26.5 0.95 29.0 28.0 30.0 36.0 30.0 31.0 31.3 2.40
cleared over 24 hr and was more marked in time increased slightly following hemodiluthe group hemodiluted with lactated Ringer’s tion and remained prolonged until the end of solution. the operation. There was a greater increase Coagulation studies. Phlebotomy and fluid in the partial thromboplastin time following replacement lowered the hematocrit from 43 hemodilution which gradually returned to 25% in group I (Table 1 Fig. 1) and to 22% toward normal. in group II (Table 2). There was also a 40% There were changes in individual coagulafall in the level of fibrinogen and a 25% tion proteins associated with the increase in decrease in platelet count immediately fol- prothrombin time and partial thromboplastin lowing hemodilution, which persisted time as shown in Tables 1 and 2. In two throughout the operation. The prothrombin patients the measured level of Factor II (pro-
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RESEARCH: VOL. 20, NO. 3, MARCH 1976
Bleeding time. The mean bleeding time prior to hemodilution was 4.4 =t 0.3 min (mean + SEM). Immediately following hemodilution, the bleeding time had increased to 15.3 i 6.7 min and remained prolonged throughout the operation (Table 1). Platelet aggregation. In view of the prolonged bleeding time, platelet aggregation was measured in three patients. Following hemodilution, aggregation with collagen, ADP, and epinephrine was normal in all three patients. In two patients, secondary aggregation with epinephrine was absent and aggregation with collagen and ADP reduced at the end of the operative procedure.
9oL.. FIG. 1. The relationship of the changesin coagulation parameters to hemodilution. All are expressed as a percentage of baseline. Prothombin time (PT) and partial thromboplastin time (PTT) were calculated from control over patient’s values and then expressed as a percentage of baseline.
thrombin) decreased immediately after hemodilution from control values of 140 and 175 mg% to 66 and 112 mg% but had returned to normal at the end of the operation. There was no change in the level of Factor V, while the level of the VII-X complex was 120 and 145 mg% and fell slightly at the end of operation to 88 and 110 mg%, respectively.
DISCUSSION Review of the clinical course of these patients showed that hemodilution effectively reduced the utilization of homologous blood without significant complications. The hemodynamic effects of hemodilution have been previously reported [14, 151. Although careful measurement of blood loss was not undertaken, it seems clear that the utilization of a mean of 1.5 units of blood for these major surgical procedures indicates significant blood conservation. The data presented here document changes in the level of several coagulation factors and in the overall rate of coagulation as measured by the prothrombin time and
TABLE 2 Effects of Hemodilution on Coagulation in Group II PTT (set) (Pt/control)
Patient
PT (set) (Pt/control)
Baseline 7 8 9 Mean f SEM
12.5/11.5 12.0112.4 11.9/11.9 12.1/11.9 0.19/O.26
24.3127.8 33.0/31.0 25.6/30.0 27.6129.6 2.7110.95
30 Min post-hemodilution 7 15.0/11.5 156112.4 8 14.3/11.9 9 Mean 15.0/11.9 f SEM 0.38/0.26
67.3127.8 60.9/31.0 28.0/30.0 52.1129.6 12.17/0.95
Platelet (10s/mm3)
Hematocrit (%)
480 252 408 380 67
240.0 680.0 302.5 407.5 137.5
39 44 48 43.6 2.60
276 60 180 172 62
175.0 55.0 267.5 166.0 61.5
23 20 23 22 1.00
Fibrinogen (mg %)
LAKS
ET AL.: NORMOVOLEMIC
HEMODILUTION
partial thromboplastin time following acute normovolemic hemodilution. There were also changes in platelet number and in platelet function, as measured by the bleeding time and platelet aggregation studies. Although the platelet count fell significantly following hemodilution, the levels reached were at no time in the range usually associated with clinical bleeding [8]. The observed mean platelet counts paralleled the fall in hematocrit, as outlined in Fig. 1. The actual platelet counts were slightly higher than that predicted from the change in hematocrit, which may be explained by release of immature platelets from bone marrow and splenic pools stimulated by the acute change in hematocrit [13, 291. Other studies of platelet count following massive transfusion for bleeding have shown that the platelet count will fall to lOO,000/mm3 after 12 units of blood have been administered [ 131.Herman et al., in a study of coagulation changes in hemorrhagic shock induced in baboons also found that the fall in platelet count was proportional to the fall in hematocrit [lo]. McNamara [19] and Miller [21], who studied coagulation defects associated with massive transfusion in man, also found the reduction in platelet count to parallel the extent of hemodilution. In addition to the decrease in the number of circulating platelets, there was a fall in the level of fibrinogen, prothrombin and Factors VII-X. These changes could also be caused by simple hemodilution. Although these decreases might account for the transient prolongation of the PT and PTT, the levels were still in the range necessary for normal hemostasis [3]. The prolonged bleeding time observed immediately after hemodilution was of considerable interest. While all the patients were thrombocytopenic, the decrease was not low enough to account for the increased bleeding time [8]. Simultaneous platelet aggregation studies were normal in all three patients following hemodilution. However, two patients had abnormal aggregation when measured at the end of their operation. This
AND
HEMOSTASIS
229
was not associated with any further increase in bleeding time. O’Brien has reported similar changes following surgery and has postulated that they are due to release of small amounts of ADP from traumatized tissue and platelets [22]. None of these patients had excess bleeding noted during surgery. Hemodilution also reduces blood viscosity and increases blood flow to skeletal muscle and skin [16]. Clinically, it was apparent that these patients had extremely warm skin, although their central body temperature was often reduced by one or two degrees. This increase in skin temperature was thought to be due to an increase in cutaneous blood flow. The marked elevation in the bleeding time might be related to this increased blood flow in cutaneous vessels rather than to an abnormality in platelet function [9]. Our study shows that phlebotomy and replacement with colloid and crystalloid solutions results in a fall in platelet count, dilution of plasma coagulation proteins, and a prolongation of the bleeding time. Most of the studies return to normal at the end of operation, following reinfusion of the patient’s freshly drawn blood. In the patient studies, there was no evidence of any increased bleeding during the procedure. Specifically, the large volume of Plasmanate infused did not appear to induce any coagulation abnormality. On the basis of these studies, we feel that acute normovolemic hemodilution associated with reinfusion of autologous blood may be a safe, effective means to support selected patients for elective surgical procedures involving major blood loss. ACKNOWLEDGMENTS authorswould like to thank Drs. F. D.
The L. Van Dam for advice and encouragement ing this work.
Moore and in complet-
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