A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection.
BACKGROUND
Hepatic resection is the most effective treatment for many malignant and benign conditions affecting the liver and biliary tree. Despite improvements, major partial hepatectomy can be associated with considerable blood loss and transfusion requirements. Transfusion of allogeneic blood products, although potentially life-saving, is associated with many potential complications. The primary aim of this study was to determine if acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces the requirement for allogeneic red cell transfusions in patients undergoing major hepatic resection.


METHODS
One hundred thirty patients undergoing major hepatic resection (> or =3 segments) were prospectively randomized to undergo either ANH or standard anesthetic management (STD). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL. Low central venous pressure anesthetic technique was used intraoperatively for both groups. A standardized transfusion protocol was applied to all patients intraoperatively and throughout the hospital stay.


RESULTS
From April 2004 to March 2007, 63 patients were randomized to ANH and 67 to STD. Demographics, diagnoses, liver function, extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, and length of hospital stay were similar between the 2 groups. ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD [12.7% (n = 8) vs. 25.4% (n = 17), respectively; P = 0.067. ANH patients were less often transfused intraoperatively (n = 1, 1.6%) compared with the STD group (n = 7, 10.4%) (P = 0.036), had higher postoperative hemoglobin levels (P = 0.01), and tended to require fewer red cell units overall (28 vs. 47 units). In patients with intraoperative blood loss > or =800 mL, ANH reduced not only the allogeneic red cell transfusion rate (18.2% vs. 42.4%, P = 0.045) but also the proportion of patients requiring fresh frozen plasma (21.1% vs. 48.3%, P = 0.025).


CONCLUSIONS
For patients undergoing major liver resection, ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use. Given the modest transfusion rate in the STD arm, future efforts should attempt to target ANH use to patients most likely to benefit.
Jarnagin
William R
WR
Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, C-887, New York, NY 10065, USA. jarnagiw@mskcc.org
Gonen
Mithat
M
Maithel
Shishir K
SK
Fong
Yuman
Y
D'Angelica
Michael I
MI
Dematteo
Ronald P
RP
Grant
Florence
F
Wuest
David
D
Kundu
Kuhali
K
Blumgart
Leslie H
LH
Fischer
Mary
M
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion / Q000379:methods*; D001804:Blood Transfusion, Autologous; D005260:Female; D005440:Fluid Therapy; D006438:Hemodilution / Q000379:methods*; D006498:Hepatectomy; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care; D011446:Prospective Studies