Standards and Best Practice for Acute Normovolemic Hemodilution: Evidence-based Consensus Recommendations

Effects of whole blood storage in a polyolefin blood bag on platelets for acute normovolemic hemodilution

“…Allogeneic blood transfusion is a common treatment for perioperative hemorrhage. Cardiac surgeries use large amounts of blood products, which consume 10–15% of the U.S. blood supply 1 . However, even small amounts of allogeneic blood transfusion increase mortality and serious complications 2 .…”

Expanding the Utilization of Acute Normovolemic Hemodilution

“…In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Shander et al revisit ANH use by providing standards and a best-practice approach based on expert panel consensus along with a thorough review of the existing literature. 13 Using a RAND-modified Delphi technique, international expert clinicians were able to agree on certain conditions that would or would not be acceptable for ANH use. After a final face-to-face multidisciplinary panel meeting, the group found 4 situations for which ANH is acceptable (based on a 9-point Likert scale).…”

“…Several other conditions, such as severe aortic stenosis, unstable angina, pulmonary hypertension, or carotid disease, received an intermediate rating, and it was determined that clinical judgment would have to be used on whether to use ANH. 13 Shander et al also acknowledged that the current literature lacks studies that show comparable dosing and ANH protocols. Therefore, they aimed to address the variability in the approach to ANH by providing a unified technique that can be adopted as needed.…”

“…They go on to describe methods for removal (via central venous access in cardiac surgical patients) and monitoring of the patient during blood collection by hemoglobin levels, hemodynamics, echocardiography, stroke variability, and cerebral oximetry. 13 Recommendations for handling and storage of collected ANH bags also are provided. What is yet to be determined are specifics such as lower and upper limits of how much blood can be removed, a minimum safe hemoglobin level to avoid extreme hemodilution, and the effect of the patient's preoperative hemoglobin and body surface area (or weight).…”

“…As Shander et al suggest, a definition for "efficacy of ANH" still is lacking. 13 Despite these remaining questions, the creation of these best practice recommendations is necessary and well-received as a first step. Shander et al should be commended for their efforts to create a standardized approach to the implementation of ANH into clinical practice for cardiac surgery patients.…”