Hemodilution and anemia in patients with cardiac disease: What is the safe limit?

Current Opinion in Anaesthesiology

Volumn 21, Issue 1, 2008, Pages 66-70

  Tircoveanu, Robert ^a   Van Der Linden, Philippe ^a,b  

^a FREE UNIVERSITY OF BRUSSELS   (Belgium)

^b BRUGMANN UNIVERSITY HOSPITAL   (Belgium)

Author keywords

Anemia; Cardiac surgery; Cardiovascular disease; Coronary artery disease; Hemoglobin; Transfusion

Indexed keywords

ANEMIA; CORONARY ARTERY BLOOD FLOW; CORONARY ARTERY OBSTRUCTION; ERYTHROCYTE TRANSFUSION; HEART DISEASE; HEART INDEX; HEART MUSCLE INJURY; HEART MUSCLE OXYGEN CONSUMPTION; HEART PROTECTION; HEART RATE; HEMATOCRIT; HEMODILUTION; HUMAN; NONHUMAN; PATIENT SAFETY; PRIORITY JOURNAL; PROGNOSIS; REVIEW; SURVIVAL TIME;

ANEMIA; ANIMALS; BLOOD TRANSFUSION; CARDIOVASCULAR DISEASES; EVIDENCE-BASED MEDICINE; HEMODILUTION; HUMANS;

EID: 38149121444     PISSN: 09527907     EISSN: None     Source Type: Journal    
DOI: 10.1097/ACO.0b013e3282f35ebf     Document Type: Review

References (44)

1. Klein HG, Spahn DR, Carson JL. Red cell transfusion in clinical practice. Lancet 2007; 370:415-426. This is a comprehensive review by three recognized experts in the field about the safety and the efficacy of red blood cell transfusion
2. Hébert PC, Fergusson DA, Stather D, et al. Revisiting transfusion practices in critically ill patients. Crit Care Med 2005; 33:7-12.
3. Shehata N, Wilson K, Mazer CD, et al. Factors affecting perioperative transfusion decisions in patients with coronary artery disease undergoing coronary artery surgery. Anesthesiology 2006; 105:19-27.
4. Kettler D. 'Permissive anaemia' compared with blood transfusion in patients with cardiac disease: another point of view. Curr Opin Anaesthesiol 1994; 7:1-4.
5. Carson JL, Duff A, Poses RM, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996; 348:1055-1060.
6. Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative hemoglobin level who decline blood transfusion. Transfusion 2002; 42:812-818.
7. Rady MY, Ryan T, Starr NJ. Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery. Crit Care Med 1998; 26:225-235.
8. Habib RH, Zacharias A, Schwann TA, et al. Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome. Crit Care Med 2005; 33:1749-1756.
9. Tang YL, Katz SD. Anemia in chronic heart failure: prevalence, etiology, clinical correlates, and treatment options. Circulation 2006; 113:2454-2461.
10. Lee PC, Kini AS, Ahsan C, et al. Anemia is an independent predictor of mortality after percutaneous coronary intervention. JACC 2004; 44:541-546.
11. Voeltz MD, Patel AD, Feit F, et al. Effect of anemia on hemorrhagic complications and mortality following percutaneous coronary intervention. Am J Cardiol 2007; 99:1513-1517.
12. Kulier A, Levin J, Moser R, et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 2007; 116:471-479. This observational study documented the clinical course of 4804 patients undergoing coronary artery surgery. A low preoperative hemoglobin per se increased the risk of postoperative adverse events. The extent of preexisting comorbidities substantially affects tolerance to perioperative anemia.
13. Carson JL, Terrin ML, Magaziner J, et al. Transfusion trigger trial for functional outcomes in cardiovascular patients undergoing surgical hip fracture repair. Transfusion 2006; 46:2192-2206. Based on an extended review of the literature, this article leads to the conclusion that much has to be learned on whether a more aggressive approach to transfusion beneficially reduces anemia-associated adverse postoperative outcomes. The authors describe in detail the study they designed and initiated in order to answer this question.
14. Vincent J-L, Sakr Y, De Backer D, Van der Linden P. Efficacy of allogeneic red blood cell transfusion. Best Pract Res Clin Anaesthesiol 2007; 21:209-219. This article reviews the effects of transfusion on mortality, morbidity and tissue oxygenation. It also addresses factors that may influence transfusion efficacy.
15. Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29:227-234.
16. Wu WC, Rathore SS, Wang Y, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345:1230-1236.
17. Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 2004; 292:1555-1562.
18. Sabatine MS, Morrow DA, Giugliano RP, et al. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation 2005; 111:2042-2049.
19. Singla I, Zahid M, Good CB, et al. Impact of blood transfusions in patients presenting with anemia and suspected acute coronary syndrome. Am J Cardiol 2007; 99:1119-1121. This retrospective study reported that transfusion in anemic patients admitted with suspected acute coronary syndrome is associated with an increase in 30-day recurrent myocardial infarction or death.
20. Carson JL, Duff A, Berlin JA, et al. Peripoperative blood transfusion and postoperative mortality. JAMA 1998; 279:199-205.
21. Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 2006; 34:1608-1616.
22. Banbury MK, Brizzio ME, Rajeswaran J, et al. Transfusion increases the risk of postoperative infection after cardiovascular surgery. J Am Coll Surg 2006; 202:131-138.
23. Levy PS, Kim SJ, Eckel PK, et al. Limit to cardiac compensation during acute isovolemic hemodilution: influence of coronary stenosis. Am J Physiol 1993; 265:H340-H349.
24. Spahn DR, Smith LR, Veronee CD, et al. Acute isovolemic hemodilution and blood transfusion. Effects on regional function and metabolism in myocardium with compromised coronary blood flow. J Thorac Cardiovasc Surg 1993; 105:694-704.
25. Spahn DR, Smith RL, Schell RM, et al. Importance of severity of coronary artery disease for the tolerance to normovolemic hemodilution. J Thorac Cardiovasc Surg 1994; 108:231-239.
26. Spahn DR, Frasco PE, White WD, et al. Is esmolol cardioprotective? Tolerance of pacing tachycardia, acute afterloading and hemodilution in dogs with cronary stenosis. JACC 1993; 21:809-821.
27. Licker M, Mariethoz E, Costa MJ, Morel D. Cardioprotective effects of acute isovolemic hemodilution in a rat model of transient coronary occlusion. Crit Care Med 2005; 33:2302.
28. Pape A, Meier J, Kertscho H, et al. Hyperoxic ventilation increases the tolerance of acute normovolemic anemia in anesthetized pigs. Crit Care Med 2006; 34:1475-1482.
29. Meier J, Kemming GJ, Kisch-Wedel H, et al. Hyperoxic ventilation reduces 6-h mortality at the critical hemoglobin concentration. Anesthesiology 2004; 100:70-76.
30. Kemming GI, Meisner FG, Meier J, et al. Hyperoxic ventilation at the critical hematocrit: effects on myocardial perfusion and function. Acta Anaesthesiol Scand 2004; 48:951-959.
31. Meier J, Pape A, Loniewska D, et al. Norepinephrine increases tolerance to acute anemia. Crit Care Med 2007; 35:1484-1492. This experimental study reported that maintenance of adequate coronary perfusion pressure by adapted norepinephrine infusion improved 6-h survival in anesthetized pigs subjected to extreme anemia.
32. Spahn DR, Schmid ER, Seifert B, Pasch T. Hemodilution tolerance in patients with coronary disease who are receiving chronic β-adrenergic blocker therapy. Anesth Analg 1996; 82:687-694.
33. Licker M, Ellenberger C, Sierra J, et al. Cardiovascular response to acute normovolemic hemodilution in patients with coronary artery diseases: assessment with transesophageal echocardiography. Crit Care Med 2005; 33:591-597.
34. Weiskopf RB, Viele MK, Feiner J, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA 1998; 279:217-221.
35. Weiskopf RB, Feiner J, Hopf H, et al. Heart rate increases linearly in response to acute isovolemic anemia. Transfusion 2003; 43:235-240.
36. Ickx B, Rigolet M, Van der Linden P. Cardiovascular and metabolic response to acute normovolemic anemia: effects of anesthesia. Anesthesiology 2000; 93:1011-1016.
37. Leung JM, Weiskopf RB, Feiner J, et al. Electrographic ST-segment changes during acute, severe isovolemic hemodilution in humans. Anesthesiology 2000; 93:1004-1010.
38. Hogue CW, Goodnough LT, Monk T. Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy. Transfusion 1998; 38:1070-1077.
39. Tonkovic D, Husedzinovic I, Barisin S, et al. Hemodynamic response to moderate dobutamine dose in OPCAB surgery during acute normovolemic hemodilution. Can J Anesth 2005; 52:214-215.
40. Cromheecke S, Lorsomradee S, Van Damme V, et al. Tolerance to acute normovolemic hemodilution with coronary artery disease depends on heart rate as determinant for myocardial oxygen consumption [abstract]. Eur J Anaesth 2006; 23:A171.
41. Licker M, Ellenberger C, Sierra J, et al. Cardioprotective effects of acute normovolemic hemodilution in patients undergoing coronary bypass surgery. Chest 2005; 128:838-847.
42. Licker M, Sierra J, Kalangos A, et al. Cardioprotective effects of acute normovolemic hemodilution in patients with severe aortic stenosis undergoing valve replacement. Transfusion 2007; 47:341-350. This randomized controlled trial documented that moderate acute normovolemic hemodilution is associated with a reduction in postoperative adverse cardiac events in patients with left ventricular hypertrophy undergoing aortic valve replacement.
43. Ferraris VA, Ferraris SP, Saha S, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the society of thoracic surgeons and the society of cardiovascular anesthesiologists clinical practice guidelines. Ann Thorac Surg 2007; 83:S27-S86. Based on available evidence, a multimodality approach involving multiple stake-holders, institutional support, enforceable transfusion algorithms supplemented with point-of-care testing and all of the blood conservation interventions that have been proven to be efficacious will provide optimal blood conservation for cardiac operations.
44. Carson JL, Terrin ML, Barton FB, et al. A pilot randomized trial comparing symptomatic vs. hemoglobin level-driven red blood cell transfusions following hip fracture. Transfusion 1998; 38:522-529.