title: Selecting patients for acute normovolemic hemodilution during hepatic resection: a prospective randomized evaluation of nomogram-based allocation.
abstract: BACKGROUND
  Acute normovolemic hemodilution (ANH) decreases transfusion rates but adds to the complexity of anesthetic management during hepatectomy. A randomized controlled trial was conducted to determine if selecting patients for ANH using a transfusion nomogram improves management and resource use compared with selection using extent of resection.
  
  
  METHODS
  One hundred fourteen patients undergoing partial hepatectomy were randomized to a clinical arm (ANH used for resection of ≥ 3 liver segments) or a nomogram arm (ANH used for predicted probability of transfusion ≥ 50% based on a previously validated nomogram). The primary end point was appropriate management, defined as avoidance of ANH in patients at low risk or use of ANH in patients at high risk for allogeneic red blood cell transfusions.
  
  
  RESULTS
  Between September 2009 and May 2011, 58 patients were randomized to the clinical arm and 56 to the nomogram arm. Demographics, diagnoses, extent of resection, blood loss, and incidence and grade of complications did not differ between the 2 groups. There were no differences in perioperative transfusions or laboratory values. Nomogram-based allocation did not change appropriate management overall (80% vs 76% in the clinical arm; p = 0.65), but did result in comparable perioperative outcomes and a trend toward decreased ANH use (30% vs 47%; p = 0.09), particularly in low blood loss (estimated blood loss ≤ 400 mL) cases (12% vs 25%; p = 0.04).
  
  
  CONCLUSIONS
  Although allocation of intraoperative management using a transfusion nomogram did not improve appropriate management overall, it more effectively identified low blood loss cases and reduced ANH use in patients least likely to benefit.
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA. frankelt@mskcc.org
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Frankel
authors.forename: Mary
authors.initials: M
authors.lastname: Fischer
authors.forename: Florence
authors.initials: F
authors.lastname: Grant
authors.forename: Jennifer
authors.initials: J
authors.lastname: Krone
authors.forename: Michael I
authors.initials: MI
authors.lastname: D'Angelica
authors.forename: Ronald P
authors.initials: RP
authors.lastname: DeMatteo
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
authors.forename: Mithat
authors.initials: M
authors.lastname: Gönen
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D003661:Decision Support Techniques; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data; D005260:Female; D006438:Hemodilution / Q000379:methods; D006498:Hepatectomy / Q000379:methods; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D049451:Nomograms; D017063:Outcome Assessment, Health Care; D018579:Patient Selection
keywords: ANH; EBL; FFP; INR; PBRC; acute normovolemic hemodilution; estimated blood loss; fresh frozen plasma; international normalized ratio; packed red blood cell