Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.
Department of Anesthesia, Cleveland Clinic, Cleveland, Ohio.
J Vasc Surg. 2021 Dec;74(6):1885-1893. doi: 10.1016/j.jvs.2021.05.030. Epub 2021 May 31.
Acute normovolemic hemodilution (ANH) is an operative blood conservation technique involving the removal and storage of patient blood after the induction of anesthesia, with maintenance of normovolemia by crystalloid and/or colloid replacement. Developed and used predominately in cardiac surgery, ANH has been applied to the vascular surgery population. However, data regarding the effects on transfusion requirements in this population are limited. The objective of the present study was to compare the transfusion requirements and coagulopathy for patients who had undergone open abdominal aortic aneurysm repair (oAAAR) using ANH to those for patients who had received only product replacements, as clinically indicated.
We performed a retrospective review of patients who had undergone elective oAAAR at a quaternary aortic referral center from 2017 to 2019. Those eligible for ANH, with no active cardiac ischemia, no valvular disease, normal left ventricular and right ventricular function, chronic kidney disease stage <3, hematocrit >38%, and a normal coagulation profile were included in the present study. Patient demographics and characteristics and operative variables, including aneurysm extent, clamp site, visceral and renal ischemia time, operative time, and transfusion requirements, were collected. Postoperative morbidity, mortality, and length of stay were analyzed. The patients with and without ANH were matched and compared. Continuous measures were analyzed using Wilcoxon rank sum tests and t tests.
During the study period, 209 oAAARs had been performed. Of the 209 patients, 76 had met the inclusion criteria. Of these 76 patients, 27 had undergone ANH and 49 had not. The patients with ANH had required fewer PRBC transfusions intraoperatively (median, 0 U; interquartile range [IQR], 0-1 U; median, 1 U; IQR, 0-2 U; P = .02), at 24 hours (median, 0 U; IQR, 0-1 U; vs median, 1 U; IQR, 0-2 U; P = .008), at 48 hours (median, 0 U; IQR, 0-1 U; vs median, 1 U; IQR, 0-2; P = .007), and throughout the admission (median, 0 U; IQR, 0-1 U; vs median, 2 U; IQR, 0-2 U; P = .011). No difference was found in the number of intraoperative platelet or cryoprecipitate transfusions. At 48 hours, the ANH group had had significantly greater platelet counts (142 ± 35.8 × 10/μL vs 124 ± 37.6 × 10/μL; P = .044), lower partial thromboplastin time, and lower international normalized ratio. No difference in myocardial infarction, return to the operating room, or mortality (one death overall). The ANH patients had a shorter length of stay (7.0 ± 2.7 vs 8.8 ± 4.8 days; P = .041).
The use of ANH during oAAAR resulted in fewer intraoperative and postoperative PRBC transfusions with improved coagulation parameters and a shorter hospital length of stay.
急性等容血液稀释（ANH）是一种手术血液保护技术，涉及在麻醉诱导后采集和储存患者的血液，并通过晶体和/或胶体替代来维持血容量正常。ANH 主要在心脏手术中开发和使用，现已应用于血管外科人群。然而，关于该人群输血需求的相关数据有限。本研究的目的是比较接受开放性腹主动脉瘤修复（oAAAR）并使用 ANH 的患者与仅根据临床需要接受产品替代的患者的输血需求和凝血功能障碍。
我们对 2017 年至 2019 年在一家四级主动脉转诊中心接受择期 oAAAR 的患者进行了回顾性研究。符合 ANH 条件、无活动性心肌缺血、无瓣膜疾病、左心室和右心室功能正常、慢性肾脏病 3 期以下、血细胞比容>38%且凝血功能正常的患者纳入本研究。收集患者的人口统计学和特征以及手术变量，包括动脉瘤范围、夹闭部位、内脏和肾脏缺血时间、手术时间和输血需求。分析术后发病率、死亡率和住院时间。比较有无 ANH 的患者。连续测量采用 Wilcoxon 秩和检验和 t 检验进行分析。
在研究期间，共进行了 209 例 oAAAR。在 209 例患者中，76 例符合纳入标准。这 76 例患者中，27 例行 ANH，49 例未行 ANH。行 ANH 的患者术中需要输注更少的红细胞（中位数 0 U；四分位距 [IQR]，0-1 U；中位数 1 U；IQR，0-2 U；P =.02）、术后 24 小时（中位数 0 U；IQR，0-1 U；vs 中位数 1 U；IQR，0-2 U；P =.008）、术后 48 小时（中位数 0 U；IQR，0-1 U；vs 中位数 1 U；IQR，0-2；P =.007）和整个住院期间（中位数 0 U；IQR，0-1 U；vs 中位数 2 U；IQR，0-2 U；P =.011）。术中血小板或冷沉淀的输注数量无差异。在术后 48 小时，ANH 组的血小板计数显著更高（142±35.8×10/μL vs 124±37.6×10/μL；P =.044）、部分凝血活酶时间更短、国际标准化比值更低。心肌梗死、重返手术室或死亡率（总体 1 例死亡）无差异。ANH 组的住院时间更短（7.0±2.7 与 8.8±4.8 天；P =.041）。
oAAAR 期间使用 ANH 可减少术中及术后红细胞输注，改善凝血参数，并缩短住院时间。
