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The Journal of Thoracic and Cardiovascular Surgery, Vol 88, 26-38, Copyright © 1984 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
RD Weisel, DC Charlesworth, LL Mickleborough, SE Fremes, J Ivanov, DA Mickle, SJ Teasdale, MF Glynn, HE Scully and BS Goldman
Blood conservation has been most successful when blood salvage techniques
have been combined with postoperative normovolemic hemodilution. The
hemodynamic and myocardial metabolic responses to normovolemic hemodilution
were assessed in a prospective randomized trial. Twenty-seven patients were
randomized to receive either blood and colloid solutions (colloid group, 13
patients) or crystalloid fluids (crystalloid group, 14 patients) following
elective coronary revascularization. Although seven patients in the
crystalloid group received blood products when the hemoglobin level fell
below 7 gm/dl, blood bank requirements were less in the crystalloid group
(colloid, 3.6 +/- 1.2 L; crystalloid, 1.5 +/- 1.0 L, p less than 0.01). The
crystalloid group received twice as much fluid to maintain normovolemia
(left atrial pressure between 8 and 10 mm Hg) in the first 72 hours
postoperatively (colloid, 6.5 +/- 1.9 L; crystalloid, 14.5 +/- 3.1 L, p
less than 0.01). The infusion of large volumes of crystalloid fluids
resulted in a progressive postoperative anemia (hemoglobin: colloid, 12.1
+/- 1.6 gm/dl, crystalloid 8.9 +/- 1.7 gm/dl, p less than 0.01, 20 hours
postoperatively). Although the crystalloid-treated patients had peripheral
edema, pulmonary edema could not be documented and there was no difference
in the physiological shunt fractions between the two groups. Preload (left
atrial pressure), afterload (mean arterial pressure), and cardiac index
were similar in the two groups. The crystalloid group had a delayed
recovery of myocardial oxygen and lactate extraction postoperatively.
Volume loading and atrial pacing 3 to 5 hours postoperatively maintained
myocardial lactate extraction in the colloid group but decreased myocardial
lactate extraction to ischemic levels in the crystalloid group. The use of
crystalloid rather than colloid fluids in the early postoperative period
conserved blood products but resulted in postoperative anemia and was
associated with a delay in myocardial metabolic recovery. Normovolemic
hemodilution should be employed with caution in patients who are at risk of
perioperative ischemic injury.
ARTICLES
Limitations of blood conservation
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