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Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 909-912  

Utility of acute normovolemic hemodilution in major surgeries in rural area: A prospective comparative study from North India

1 Department of Anaesthesiology, MRA Medical College, Ambedkar Nagar, Uttar Pradesh, India
2 Department of Surgery, MRA Medical College, Ambedkar Nagar, Uttar Pradesh, India
3 Department of Otorhinolaryngology, MRA Medical College, Ambedkar Nagar, Uttar Pradesh, India
4 Department of Orthopaedics, MRA Medical College, Ambedkar Nagar, Uttar Pradesh, India
5 Department of Surgery, Government Medical College, Azamgarh, Uttar Pradesh, India

Date of Web Publication28-Nov-2017

Correspondence Address:
Sujeet Rai
Department of Anaesthesiology, MRA Medical College, Ambedkar Nagar - 224 227, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_86_17

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Introduction: Easy availability of autologous blood is difficult in rural areas. Acute normovolemic hemodilution (ANH) has been found to be an effective alternative in major surgeries where we are expecting major blood loss. Patients and Methods: A prospective comparative study was designed to evaluate the utility of ANH patients (patients receiving autologous blood) during major operations done at MRA Medical College Ambedkar Nagar, Uttar Pradesh, India. during from September 2015 to September 2016. A total of 60 patients undergoing major surgeries were randomly assigned into two groups of thirty patients' each. Group I received homologous blood intraoperative only when required. In Group II ANH was initiated to a target hematocrit of 30% after induction of anesthesia. Various parameters such as demographic, biochemical, and hemodynamic were compared. Results: The mean value of blood withdrawn in ANH group was 650.5 ± 228 ml and it was replaced with an equal volume of 6% hydroethyl starch. There was no statistically significant variation in mean hemocrits levels in both the groups at various stages of the study. Hematocrits decreased significantly in both the groups at various stages as compared to preoperative values. The heart rate and mean blood pressure were almost similar and without statistically significant differences in both groups. Surgical blood loss in Group I was 895.29 ± 568.30 ml as compared to 765 ± 506 ml in Group II. The difference was statistically insignificant (P ≥ 0.05). The mean volume of homologous blood transfused in Group I was 850.71 ± 318.29 ml, as compared to nil in Group II which was statistically significant (P < 0.05). Conclusion: It concludes that ANH up to a target hematocrit of 30% is safe and effective in reducing the need for homologous blood in various major surgeries in institutes in rural areas.

Keywords: Autologous, homologous, normovolemic hemodilution, surgery

How to cite this article:
Rai S, Verma S, Yadav PK, Ahmad J, Yadav HK. Utility of acute normovolemic hemodilution in major surgeries in rural area: A prospective comparative study from North India. Anesth Essays Res 2017;11:909-12

How to cite this URL:
Rai S, Verma S, Yadav PK, Ahmad J, Yadav HK. Utility of acute normovolemic hemodilution in major surgeries in rural area: A prospective comparative study from North India. Anesth Essays Res [serial online] 2017 [cited 2020 May 30];11:909-12. Available from:

   Introduction Top

Acute normovolemic hemodilution (ANH) has been sed for the past many years, and its aim is to reduce or even avoid the need for transfusion of homologous blood during the perioperative period.[1] There are many major surgeries in general surgery, orthopedic head and neck surgeries where we expect major blood loss during operation.[1],[2],[3]

In our remote areas of North India, availability of homologous blood for transfusion is often very limited, so we think of blood conservation strategies such as pre-operative autologous blood collection, intra- and post-operative salvage of the patient's blood and re-transfusion, acceptance of lower hemoglobin level trigger for transfusion and adopting a very meticulous surgical technique. Various complications of homologous blood transfusion such as mismatched transfusion risk of infection, transmission of many diseases can be minimized using these alternatives.[1],[2]

In ANH patient's blood is removed in anticoagulant containing blood bags, either immediately before or shortly after induction of anesthesia and is simultaneously replaced with an appropriate volume of crystalloids and/or colloids to maintain normovolemia using Formula of Gross.[4]

Crystalloid in the ration of 3:1 and colloid in the ration of 1:1 using the original equation of Gross.[4]

Where VL = blood volume (ml) to be withdrawn, EBV = estimated total blood volume of the patient (ml), PCV0 = initial PCV (%), PCVF = patient' minimal allowable PCV and PCVAV = average.

Appropriate patient selection, proper monitoring, and adequate intraoperative volume replacement are mandatory for this technique to be carried out safely.

   Patients and Methods Top

With the approval of the Institutional Ethics Committee, we conducted a prospective randomized study of adult patients who were scheduled for an elective major head and neck surgery, orthopedic surgeries to be done in general anesthesia. All the patients signed informed consent to participate in the study. All patients belonged to the American Society of Anesthesiologists (ASA) – Grade I or II, age 18–60 years, of either sex, weighing more than 45 kg and baseline preoperative hematocrits more than 35% were included in the study. Exclusion criteria were pregnancy, ischemic heart disease, carotid artery disease, hemoglobin below 10% g, abnormal preoperative coagulation tests or platelets count, renal insufficiency (preoperative plasma creatinine >2.0 mg/dL), body weight below 45 kg or above 120 kg, and administration of blood (packed cells) before surgery and who refuse. Patients who participated in the study were randomly divided into two groups, using sealed envelope method: Group 1 – control group, Group 2 – ANH group.

In the ANH group, after induction of general anesthesia, the blood (amount is expecting blood loss) intermittently was withdrawn from the patients and were stored in a routine blood bag to prevent clotting. At the end of the operation or in the recovery room, the collected blood was re-transfused to the patients. For both groups, normal aseptic guidelines were followed during harvesting. The blood was kept at room temperature to keep the platelet function as optimal as possible. An equal amount of blood was replaced by 6% hydroxyethyl starch (HES) to the patients in ANH group. The targeted hematocrit level for hemodilution for all patients was 30%. The need for fluid infusion was closely monitored. If necessary autologous blood was infused. In the control group, there was no autotransfusion, and just homologous blood (blood of same blood group) was used as needed.

Hematocrit before the operation, during operation and 24 h after the operation were checked. Hemodynamic studies such as blood pressure, pulse rate, and electrocardiogram were monitored during operations and at the end of operation. The amount of the total blood needed in each group was measured at the end of the operation also. Independent sample t-test was used to compare means between the two groups. P < 0.05 was considered statistically significant.

   Results Top

Both groups were statistically comparable with respect to age, weight, sex, and duration of surgery [Table 1]. The average age was 45.9 and 48.5 years in ANH group and control group respectively.
Table 1: Demographic data in the two groups (mean±standard deviation)

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Mostly orthopedic and ENT surgeries were performed in both groups. There was no significant difference with respect to nature of surgery in the two groups (P > 0.05) [Table 2].
Table 2: Surgical specialty.wise distribution of cases (n=60)

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24 h postoperational mean hematocrit was 35 ± 2 and 34 ± 1.5 in the control and ANH group (P = 0.28) indicates blood supply has been appropriate in both groups. The mean total blood transfused to the control and ANH group was 1040 ml and 1150 ml, respectively (P = 0.76).

There were significant differences between the two groups regarding the total amount of the homologous blood needed during operation (as per requirement intra-operatively) (P ≤ 0.05). Homologous blood was not required in any patient of ANH group in our study.

The amount of surgical blood loss in Group I was 895.29 ± 568.30 ml, whereas, in Group II, 765 ± 506.22 ml of blood was lost during surgery. The difference in blood loss between Group I and Group II was statistically insignificant (P > 0.05). The mean volume of homologous blood transfused in Group I patients (control group) was 850.71 ± 318.29 ml, compared to nil ml in Group II (ANH group) [Table 3] and [Table 4].
Table 3: Hematological and hemodynamic parameters at various stages of Group I (control)

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Table 4: Hematological and hemodynamic parameters at various stages of Group II (acute normovolemic hemodilution) (mean±standard deviation)

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The amount of autologous blood withdrawn and re-transfused in Group II was 650.5 ± 228 ml. All patients (100%) in Group I received homologous blood. In Group II, no patients received homologous blood [Table 3] and [Table 4].

The hematological and hemodynamic changes in two groups are summarized in [Table 2] and [Table 3]. The baseline (preoperative) hemoglobin value averaging 12.10 ± 1.52 g/dl in Group I and 12.15 ± 1.25 g/dl in Group II, were statistically comparable. When compared to baseline values, a significant fall in hemoglobin was observed in both the groups during various stages of surgery (P < 0.05). Although mean hemoglobin levels at maximum blood loss and after transfusion of blood in Group II were lower than in Group I, yet the variation between the groups at different stages was statistically insignificant (P > 0.05). In Group II, during blood drainage and hemodilution, the hematocrit decreased significantly from an initial average hematocrit value of 39.5% to a mean of 31.24 ± 2.96% at maximum blood loss, which when compared with group I at the same stage was statistically significant (P < 0.05). On all other occasions, the variation in mean hematocrit value between the two groups was statistically insignificant. The hemodynamic parameters at various stages of the study were well maintained in both the groups. The heart rate and mean arterial pressure did not differ significantly between the two groups [Table 3] and [Table 4].

   Discussion Top

Use of ANH and autologous blood transfusion as a practice to reduce the use of homologous blood was recommended by the National Institute of Health Consensus Conference.[5],[6]

ANH and autologous blood transfusion have decreased not only the need for intraoperative homologous blood transfusion but also the hazards associated with it. Autologous blood collected on the operation table before surgery and stored at room temperature has viable platelets and clotting factors in addition to other constituents of blood.[7],[8]

ANH has been employed from limited to the extreme degree of dilution.[9] Hemodilution up to 27%–30% hematocrit value is called moderate hemodilution, and it is the acceptable value for elective surgery of ASA Grade I patients even without hemodilution.[3],[9],[10]

In this study, ANH was performed to a target hematocrit of 30% using 6% HES. The removal of autologous blood units and hemodilution was accompanied with hemodynamic stability. We did not observe any significant changes in heart rate; although, the decrease in heart rate during hemodilution has been reported.[11] An increase in heart rate during hemodilution usually indicates hypovolemia, too low Hct or insufficient oxygen transport.[11],[12] Statistically, significant fall in blood pressure during hemodilution has been observed by Kafer et al.[13]

In this study, we used 6% HES as the replacement fluid. HES solution is physiologically compatible and contains spherical, branched chains of glucose molecules like glycogen.[11] Watzek et al. have demonstrated safety with the use of HES as diluents during ANH.[14]

The efficacy of ANH for reducing the use of homologous blood has remained a controversial issue.[11] Monk et al. also revealed that ANH was a safe, effective, and inexpensive method of blood conservation.[15] In contrast, Naqash et al., where five patients (25%) needed homologous blood in ANH group, compared to control group where all (100%) needed homologous blood transfusions.[11]

The results of this study indicate that ANH with Auto-transfusion is a safe and feasible technique to reduce intraoperative blood loss. The need for homologous blood transfusion in patients and also its cost, being operated in rural area institutes decreases significantly. However, the use of controlled hypotension in combination with ANH can further improve the outcome.

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Conflicts of interest

There are no conflicts of interest.

   References Top

de Araújo LM, Garcia LV. Acute normovolemic hemodilution: A practical approach. Open J Anesthesiol 2013;3:38-43.  Back to cited text no. 1
Leiser Y, Barak M, Kubichka A, Peled M, Katz Y, Abu El-Naaj I. Acute normovolemic hemodilution in patients undergoing head and neck surgery: A prospective randomized trial. J Anesthesiol Clin Sci 2013;2:30.  Back to cited text no. 2
Khoshraftar E, Hassan M, Mohammad HB, Nahid M, Sanie JM. The comparison of acute normovolemic hemodilution with allogenic blood transfusion in patients who underwent femoral fracture surgery. Arch Anesthesiol Crit Care 2015;1:84-7.  Back to cited text no. 3
Gross JB. Estimating allowable blood loss: Corrected for dilution. Anesthesiology 1983;58:277-80.  Back to cited text no. 4
National Institute of Health (NIH). Consensus conference: Perioperative RBC transfusion. JAMA 1988;260:2700-3.  Back to cited text no. 5
Ono K, Shibata J, Tanaka T, Sakamoto A, Hasegawa J, Tanaka S, et al. Acute normovolemic hemodilution to reduce allogenic blood transfusion in patients undergoing radical cystectomy. Masui 2009;58:160-4.  Back to cited text no. 6
Shidhaye RV, Divekar DS, Lakhkar V, Lakhkar V, Shidhaye R. Comparative study of acute normovolaemic haemodilution and acute hypervolaemic haemodilution in major surgical procedures. Anaesth Pain Intensive Care 2010;14:21-6.  Back to cited text no. 7
Hursch D, Aldrete JA, Hanna LS. Isovolemic hemodilution: A comparative study of diluents. Anesth Analg 1988;67:100.  Back to cited text no. 8
Olsfanger D, Fredman B, Goldstein B, Gillion J. Acute normovolemic hemodilution in elective major surgery. Transfusion 1994;34:269-71.  Back to cited text no. 9
Winter V, Gille J, Richter A, Sablotzki A, Wiedemann B. Preoperative hypervolemic hemodilution with 6% hydroxyethyl starch 130/0,4 (HES 130/0.4) solution as a way of reducing needs for donor blood transfusion. Anaeteziol Reanimatol 2006;2:43-7.  Back to cited text no. 10
Naqash IA, Draboo MA, Lone AQ, Nengroo SH, Kirmani A, Bhat AR. Evaluation of acute normovolemic hemodilution and autotransfusion in neurosurgical patients undergoing excision of intracranial meningioma. J Anaesthesiol Clin Pharmacol 2011;27:54-8.  Back to cited text no. 11
[PUBMED]  [Full text]  
Messmer K. Hemodilution – Possibilities and safety aspects. Acta Anaesthesiol Scand Suppl 1988;89:49-53.  Back to cited text no. 12
Isley MR, Kafer ER, Lucoas WT, Maccioli GA, Omen HG, Hansen T, et al. Automated acute normovolemic hemodilution reduces blood transfusion requirements for spinal; fusion. Anesth Analg 1986;65:(supply-1)576.  Back to cited text no. 13
Watzek G, Watzek C, Draxler V, Fürnschlief E. Experience with “isovolaemic” haemodilution in extensive surgery for oro-facial tumours. J Maxillofac Surg 1980;8:131-4.  Back to cited text no. 14
Monk TG, Goodnough LT, Brecher ME, Pulley DD, Colberg JW, Andriole GL, et al. Acute normovolemic hemodilution can replace preoperative autologous blood donation as a standard of care for autologous blood procurement in radical prostatectomy. Anesth Analg 1997;85:953-8.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4]


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