title: Cerebral effects and blood sparing efficiency of sodium nitroprusside-induced hypotension alone and in combination with acute normovolaemic haemodilution.
abstract: The combined reduction of oxygen-carrying capacity and perfusion pressure during the combination of acute normovolaemic haemodilution (ANH) and controlled hypotension (CH) raises concerns of hypoperfusion and ischaemic injury to the brain. Forty-two patients undergoing radical prostatectomy were prospectively allocated to receive CH induced by sodium nitroprusside (mean arterial pressure (MAP) 50 mm Hg), a combination of CH+ANH (post-ANH haematocrit 29%; intraoperative MAP 50 mm Hg), or standard anaesthesia (control). Serum levels of the brain-originated proteins neuron-specific enolase (NSE) and protein S-100, blood loss, transfusion requirements, adverse effects, and postoperative recovery profile were compared among the three groups. Intraoperative blood loss in the CH group (mean (SD)) (788 (193) ml) and CH+ANH group (861 (184) ml) was significantly less than in the control group (1335 (460) ml). Significantly fewer total units of allogeneic packed red blood cells (PRBC) were transfused in the patients receiving hypotensive anaesthesia (CH, 3 units; CH+ANH, 2 units; control, 17 units). There was no difference in immediate postoperative recovery profile among the three groups as determined by the emergence from anaesthesia and time to discharge from the postanaesthesia care unit. Serum S-100 protein concentrations increased significantly in all groups from baseline to peak concentrations 2 h postoperatively (CH 0.25 (0.11) microg litre(-1); CH+ANH 0.31 (0.12) microg litre(-1); control 0.31 (0.10) microg litre(-1)). A return to baseline values was seen within 24 h postoperatively in all patients. No changes in NSE concentrations were seen. Our observations suggest that CH and CH+ANH were effective in reducing blood loss and transfusion requirements in patients undergoing radical prostatectomy. Increased serum S-100 protein concentrations imply a disturbance in astroglial cell membrane integrity and an increased endothelial permeability of the blood-brain barrier. There were no associations between serum S-100 protein or NSE and adverse cognitive effects. Further work needs to be done to determine the prognostic importance of S-100 protein and NSE as surrogate variables of postoperative cerebral complications.
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Akademisches Lehrkrankenhaus der Universität Mainz, Germany.
authors.forename: S W
authors.initials: SW
authors.lastname: Suttner
authors.forename: S N
authors.initials: SN
authors.lastname: Piper
authors.forename: K
authors.initials: K
authors.lastname: Lang
authors.forename: I
authors.initials: I
authors.lastname: Hüttner
authors.forename: B
authors.initials: B
authors.lastname: Kumle
authors.forename: J
authors.initials: J
authors.lastname: Boldt
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001921:Brain / Q000503:physiopathology*; D003131:Combined Modality Therapy; D017707:Erythrocyte Transfusion; D006438:Hemodilution; D006488:Hemostasis, Surgical / Q000379:methods; D006801:Humans; D007023:Hypotension, Controlled / Q000379:methods*; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009599:Nitroprusside; D010751:Phosphopyruvate Hydratase / Q000097:blood; D011446:Prospective Studies; D011468:Prostatectomy; D009418:S100 Proteins / Q000097:blood
chemical_list: D015415:Biomarkers; D009418:S100 Proteins; D009599:Nitroprusside; D010751:Phosphopyruvate Hydratase