Koroner by-pass cerrahisinde akut normovolemik hemodilüsyonun koagülasyon parametrelerine etkisi
Akut normovolemik hemodilüsyon operasyon sırasında allojenik kan transfüzyonu gereksinimini azaltır. Akut normovolemik hemodilüsyonun kardiyopulmoner by-pass sonrası hemostaza etkilerini, rutin koagülasyon testleri, trombin-antitrombin III kompleksi, fibrinojen, D-dimer, protein C ve S düzeylerini karşılaştırarak değerlendirmeyi amaçladık. Etik Kurul onayından sonra koroner arter by-pass operasyonu uygulanacak 40 olgu rasgele iki gruba ayrıldı. Anestezi indüksiyonundan sonra Grup l (n=20)'den hematokrit < %35 oluncaya kadar bir veya iki ünite kan alındı. Aynı zamanda, periferik venden eşit miktarda kolloid sıvı verilerek volüm replasmanı sağlandı. Grup H (n=20)'ye ek işlem yapılmadı. Tüm koagülasyon testleri indüksiyondan önce, operasyon sonunda, postoperatif 6. ve 24. saatlerde; fibrinojen, trombin-antitrombin III kompleksi ve D-dimer ise bu ölçüm periyotlarına ek olarak kardiyopulmoner by-passtan önce ölçüldü. Transfüze edilen allojenik kan miktarı Grup l'de Grup II'ye göre daha düşüktü (p
The effects of acute normovolemic hemodilution on coagulation parameters in coronary artery bypass surgery
Acute normovolemic hemodilution reduces allogenic blood transfusion requirements during surgery. We aimed to investigate the effects of acute normovolemic hemodilution on hemostasis after cardiopulmonary bypass by comparing routine coagulation tests, thrombin-antithrombin III complex, fibrinogen, D-dimer, protein C and S levels. After Ethics Committee approval 40 patients undergoing coronary artery bypass surgery were divided into two groups randomly. After induction of anesthesia, one or two units of blood were drawn from the Group I (n=20) until the hematocrit values became less than < 35% (Htc < 35%). At the same time, volume replacement was achieved with same amount of colloid infusion from peripheral veins. No additional procedure was done to Group II (n=20). All coagulation tests were measured be-fore induction, at the end of surgery, at postoperative 6 th and 24 th h. In addition to this time periods, thrombin-antithrombin III complex, fibrinogen and D-dimer levels were measured before cardiopulmonary bypass. The amount of transfused allogenic blood was lower in Group I compared to Group II (p<0.05). Routine coagulation tests remained within normal limits. Before cardiopulmonary bypass, fibrinogen, thrombin-antithrombin III complex and D-dimer levels were higher in Group I compared to Group II statistically (p<0.05). Protein C level was less at the end of surgery in Group I (p<0.05). Fragmentation ratio was detected lower in Group I than Group II (p<0.01). We concluded that, although acute normovolemic hemodilution reduces allogenic blood transfusion requirement and fragmentation ratio, it may activate coagulation and fibrinolysis in patients undergoing coronary artery bypass surgery.
___
- 1. Johnson RG, Thurer RL, Kruskall MS, et al: Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg 1992; 104:307-14.
- 2. Goodnough LT, Johnston MFM, Toy PTCY: The variability of transfusion practice in coronary artery bypass surgery. JAMA 1991; 265:86-90.
- 3. Kytölâ L, Nuutinen L, Myllyla G: Transfusion policies in coronary artery bypass - a nationwide survey in Finland. Acta Anaesthesiol Scand 1998; 42:178-83.
- 4. Höhn L, Schweizer A, Licker M, Morel DR: Absence of beneficial effect of acute normovolemic hemodilution combined with aprotinin on allogenic blood transfusion requirement in cardiac surgery. Anesthesiology 2002; 96:276-82.
- 5. Stehling L, Hauder ZL: Acute normovolemic hemodilution. Transfusion 1991; 31:857-68.
- 6. Spahn DR, Leone BJ, Reves Jg, Pasch T: Cardiovascular and coronary physiology of acute isovolemic hemodilution: A review of nonoxygen-carrying and oxygen-carrying solutions. Anesth Analg 1994; 78:1000-21.
- 7. Tanaka K, Takao M, Yada I, Kusagawa M, Deguchi K: Alterations in coagulation and fibrinolysis associated with cardiopulmonary bypass during open heart surgery. J Cardiothorac Anesth 1989;3:181-8.
- 8. Brister SJ, Ofosu FA, Buchanan MR: Thrombus generation during cardiac surgery: Is heparin the ideal anticoagulant. Thromb Haemost 1993; 70:259-62.
- 9. Walters I, Menges T, Ballesteros M, et al: Thrombin generation and activation of the thrombomodulin protein C system in open heart surgery depend on underlying cardiac disease. Thrombosis Research 1998; 92:1-9.
- 10. Keohamba GS, Pfeffer TA, Sintek CF, Khonsari S: Intraoperative autotransfusion reduces blood loss after cardiopulmonary bypass. Ann Thorac Surg. 1996; 61:900-3.
- 11. Flom-Halvorsen HI, 0vrum E, Tangen G, et al: Autotransfusionin coronary artery bypass grafting: Disparity in laboratory tests and clinical performance. J Thorac Cardiovasc Surg 1999; 118:610-7.
- 12. Boisclair MD, Lane DA, Philippou H, et al: Mechanisms of thrombin generation during surgery and cardiopulmonary bypass. Blood 1993; 82:3350-7.
- 13. Slaughter TF, LeBleu TH, Douglas JM Jr, et al: Characterization of prothrombin activation during cardiac surgery by hemostatic molecular markers. Anesthesiology 1994; 80:520-6.
- 14. Ruttmann TG, James MFM, Aronson I: In vivo investigation into the effects of haemodilution with hydroxyethyl starch (200/0.5) and normal saline on coagulation. Br J Anaesth 1998; 80:612-6.
- 15. Heilman L, Hojnacki B: Die Bedeutung der haemodilutionstherapie in der Schwangerschaft. Acta Medica Austriaca 1991; 91:56-9.
- 16. Ceriello A, Pirisi M, Giacomello R, et al: Fibrinogen plasma levels as a marker of thrombin activation: New insights on the role of fibrinogen as a cardiovascular risk factor. Thromb Haemost 1994; 71:593-5.
- 17. Ruttmann TG, James MFM, Viljoen JF: Haemodilution induces a hypercoagulable state. Br J Anaesth 1996; 76:412-4.
- 18. Ruttmann TG, James MFM Finlayson J: Effect on coagulation of intravenous crystalloid or colloid in patients undergoing peripheral surgery. Br J Anaesth 2002; 89:226-30.
- 19. Bovill EG: Disseminated intravascular coagulation: pathophysiology and laboratory diagnosis. Fibrinolysis 1993; 7 (Suppl 2); 17-9.
- 20. Dunn ID, Hui ACW, Triffit PD, et al: Plasma D-dimer as a marker for postoperative deep venous thrombosis. Thromb Haemost 1994; 72:663-5.
- 21. Olsfanger D, Fredman B, Goldstein B, et al: Acute normovolaemic haemodilution decreases postoperative allogenic blood tranfusion after total knee replacement. Br J Anaesth 1997; 79:317-21.
- 22. Hobisch-Hagen P, Wirleitner B, Mair J, et al: Consequences of acute normovolemic haemodilution on haemostasia during major orthopaedic surgery. Br J Anaesth 1999; 82:503-9.
- 23. Boldt J, Schindler E, Walters I, et al: The effect of anticoagulation regimen on endothelial-related coagulation in cardiac surgery patients. Anaesthesia 1995; 50:954-60.
- 24. Morgan GE, Mikhail MS, Murray MJ, Larson CP, editors. Clinical Anesthesiology. 3rd ed. USA, McGraw-Hill, 2002, 708-22.