Institutional members access full text with Ovid®

Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy: Results of a Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared With Standard Intraoperative Management

Fischer, Mary MD*; Matsuo, Kenichi MD; Gonen, Mithat MD; Grant, Florence MD*; DeMatteo, Ronald P. MD; D’Angelica, Michael I. MD; Mascarenhas, Jennifer MD*; Brennan, Murray F. MD; Allen, Peter J. MD; Blumgart, Leslie H. MD; Jarnagin, William R. MD

doi: 10.1097/SLA.0b013e3181ff36b1
Randomized Controlled Trials: ORIGINAL STUDY

Background: Pancreaticoduodenectomy (PD) can be associated with significant blood loss and transfusion requirements, with potential adverse short- and long-term consequences. The aim of this study was to determine whether acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces perioperative allogeneic transfusions in patients undergoing PD.

Methods: One hundred thirty patients undergoing PD were randomized to ANH or standard management (STDM). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL; crystalloid and colloid were used for volume replacement. Strict transfusion triggers were applied during and after operation. Perioperative complications were prospectively assessed and graded for severity.

Results: From July 2005 to May 2009, 209 patients were registered, 79 excluded, 65 were randomized to ANH, and 65 to STD. The groups were well matched for demographic, operative, and histopathologic variables. Patients undergoing ANH received over 2 L more fluid intraoperatively (6250 mL, range 2000–11850) compared with patients undergoing STD (3900 mL, range 2000–9000) (P < 0.001). Transfusion rates were similar (ANH = 16.9%, 30 units vs STD = 18.5%, 33 units; P = 0.82), as was overall perioperative morbidity (ANH = 49.2% vs STD = 47%, P = 0.86). There was, however, a trend toward more grade-3 complications in patients undergoing ANH (32% vs 23.1% STD, P = 0.17), and complications related to the pancreatic anastomosis (leak/fistula/abscess) were significantly higher in the ANH group (21.5% vs 7.7%, P = 0.045). The intraoperative fluid volume was higher for all patients with pancreatic anastomotic complications (n = 19), regardless of randomization arm (ANH 6000 mL, range 2800–11350 mL vs STD 5000 mL, range 2000–11850 mL, P < 0.042).

Conclusion: In this randomized trial of patients undergoing PD, ANH did not reduce allogeneic transfusions and resulted in more pancreatic anastomotic complications, likely related to greater intraoperative fluid administration. The benefits of ANH do not necessarily extend to all procedures, and restrictive intravenous fluid management during PD may help improve postoperative outcome.

This prospective, randomized trial analyzed the impact of acute normovolemic hemodilution (ANH) on transfusion rates in patients undergoing pancreaticoduodenectomy. ANH was not associated with a reduction in transfusion of allogeneic blood products but did result in a significant, nearly 3-fold increase in complications related to the pancreatic anastomosis, a difference that appears to be related to greater intravenous fluid in the experimental arm.

*Departments of Anesthesiology, Memorial Sloan-Kettering Cancer Center, New York.

Departments of Surgery, Memorial Sloan-Kettering Cancer Center, New York.

Departments of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York.

Reprints: William R. Jarnagin, MD, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065. E-mail: jarnagiw@mskcc.org.

This study is registered at clinicaltrials.gov and carries the ID number NCT00200148.

This prospective, randomized trial analyzed the impact of acute normovolemic hemodilution (ANH) on transfusion rates in patients undergoing pancreaticoduodenectomy (PD). Acute normovolemic hemodilution was not associated with a reduction in transfusion of allogeneic blood products but did result in a significant, nearly 3-fold increase in complications related to the pancreatic anastomosis, a difference that seems to be related to greater intravenous (IV) fluid in the experimental arm.

© 2010 Lippincott Williams & Wilkins, Inc.