Journal of Clinical Orthopaedics and Trauma 11 (2020) S844eS848

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Journal of Clinical Orthopaedics and Trauma

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Acute normovolemic hemodilution in major orthopedic surgery

Naveen Bansal a, *, Gagandeep Kaur a, Sudhir Garg b, Satinder Gombar c
a
Department of Transfusion Medicine, Government Medical College Hospital, Chandigarh, India
b
Department of Orthopedics, Government Medical College Hospital, Chandigarh, India
c
Department of Anesthesiology, Government Medical College Hospital, Chandigarh, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: With increasing concerns regarding the newer emerging pathogens, alternatives to allo-
Received 18 March 2020 geneic blood transfusion are being explored and acute normovolemic hemodilution (ANH) is one of
Received in revised form them.
5 June 2020
Methods: A prospective study was conducted in patients aged 18e65 years with preoperative hemo-
Accepted 8 June 2020
Available online 11 June 2020
globin >12 g/dl undergoing total knee replacement or total hip replacement. Patients in whom hemo-
dilution was performed were included in the ANH group whereas patients undergoing treatment as per
the routine hospital protocol were included in the control group.
Keywords:
Autologous blood
Results: Preoperative hemoglobin was similar in both ANH and control groups (12.7 ± 0.7 vs 12.6 ± 0.6,
Hemodilution p ¼ 0.56). Allogeneic blood requirement was significantly less in the ANH group as compared to the
Orthopedic surgery control group (4 vs 15, p ¼ 0.001). Postoperative complications were significantly lower in ANH group as
Acute normovolemic hemodilution compared to control group (7 vs 16, p ¼ 0.01).
Conclusions: ANH can be an alternative approach to meet the need of safe blood especially in resource
constrained countries, like India where risk of transfusion transmitted infections are still high and where
there is high demand of blood and acute shortage of blood in hospitals.
© 2020 Delhi Orthopedic Association. All rights reserved.

1. Introduction
Allogeneic blood transfusion has various inherent risks
including transmission of existing and newer emerging pathogens.1
Transfusion associated immunomodulation, which results in tran-
sient suppression of immune system can also occur as a result of
allogeneic blood transfusion. Over the past decades, there have
been several advances in the laboratory diagnosis of transfusion
transmitted infections (TTI). However, blood safety remains a major
concern and therefore, alternative methods to allogeneic blood
transfusion have been explored and autologous blood transfusion is
one of them.2 ANH is most effective in surgeries that are associated
with large amount of blood loss.3
With the increasing public awareness of transfusion transmitted
infections, autologous procedures are being increasing used during
elective surgeries. Although acute normovolemic hemodilution
* Corresponding author. Department of Lab Medicine, ESIC Model Hospital,
Baddi, Himachal Pradesh, 173205, India.
E-mail addresses: drnaveenbansal87@gmail.com (N. Bansal), docvpsingh@
yahoo.co.in (G. Kaur), sudhir_ortho@yahoo.com (S. Garg), dr_sgombar@rediffmail.
com (S. Gombar).
(ANH) was introduced around three decades ago, it has not
emerged as a standard intervention. Total knee replacement (TKR)
and total hip replacement (THR) are major orthopedic surgeries
which are associated with frequent need for blood transfusion.4
Hence, this study was planned to get an insight into the efficacy
of ANH in patients undergoing major orthopedic surgeries. The null
hypothesis was that there is no difference in allogeneic blood
requirement in ANH group and patients undergoing TKR/THR as
per routine hospital protocol.
2. Materials and methods
2.1. Patient selection, study design, procedure
The present study was a prospective, interventional study,
conducted over a period of 19 months in patients undergoing major
orthopedic surgery (total hip replacement, total knee replacement,
fracture of hip). Using computer generated numbers, the enrolled
patients were randomly allocated to the following two groups:
Patients in whom ANH was performed were included in the ANH
group whereas patients who underwent TKR/THR as per routine
hospital protocol were included in the control group as shown in

https://doi.org/10.1016/j.jcot.2020.06.017
0976-5662/© 2020 Delhi Orthopedic Association. All rights reserved.

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Fig. 1.
The patients who met the following criteria were included in the
study: (i) age >18 years but <65 years; (ii) American Society of
Anesthesiologists (ASA) physical status I/II; (iii) expected blood loss
greater than 750 ml but less than 1500 ml; (iv) pre operative he-
moglobin >12 g/dl.
Patients with the following conditions were excluded from the
study: (i) history of ischemic heart disease; (ii) suffering from renal
or hepatic insufficiency; (iii) suffering from any active systemic
infection; (iv) on anticoagulant therapy at the time of operation.
ANH was performed after induction of anesthesia and before
start of surgery by collecting blood in standard blood transfusion
bags. The following formula was used to calculate the amount of
blood which was withdrawn.5
Volume of blood collected ¼ EBV x (Hi e Ht)/ Hav
where EBV ¼ estimated blood volume (65 ml/kg for women and
70 ml/kg for men); Hi ¼ initial hematocrit; Ht ¼ target hematocrit;
Hav ¼ average hematocrit ¼ (Hi þ Ht)/2.
The collected blood was kept in the operation theatre at room
temperature. Ringer lactate was used as replacement fluid and for
every 1 ml of blood withdrawn, 3 ml of ringer lactate was infused in
the patient. Swab weighing method was used for calculating the
amount of blood loss during surgery.6 After completion of the
surgery, the reinfusion of blood was done in reverse order, i.e. the
unit that was collected at last was reinfused first. Allogeneic blood
was transfused if a trigger hemoglobin level of 9 g/dl was reached
or as per the discretion of the attending anesthesiologist. Heart rate
(HR), blood pressure (BP) and oxygen saturation (SpO2) were
regularly recorded at every 10 min interval during the surgical
procedure.
A blood sample was withdrawn at the following time points: (i)
after completion of hemodilution, (ii) after completion of surgery,
(iii) 24 h after completion of surgery and (iv) at the time of
discharge from hospital and was evaluated for hemoglobin, he-
matocrit, prothrombin time index and platelet count. Patients were
followed up till discharge from the hospital. They were investigated
for any postoperative complications including fever, local/surgical
site infection, sepsis, urinary tract infection and any transfusion

Fig. 1. CONSORT diagram showing the progression of participants through the study.

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Table 1 Table 3
Variation in hematological variables. Post operative complications.

ANH group Control group p-value* ANH group Control group

Hemoglobin (g/dl) Fever 7 16

Pre-operative 12.7 ± 0.7 12.6 ± 0.6 0.56 UTI 1 2
After hemodilution 11.6 ± 0.4 - - Sepsis 0 1
After surgery 10.4 ± 0.7 11.1 ± 0.6 0.0002 Wound infection 0 0
Post operative day 1 10.0 ± 0.7 10 ± 0.6 0.72 Transfusion reaction 0 1
At discharge 10.8 ± 0.6 11.1 ± 0.5 0.17
UTI¼ Urinary tract infection.
Hematocrit (%)
Pre-operative 38.5 ± 2.6 38.9 ± 2.5 0.46
After hemodilution 34.3 ± 1.5 - -
After surgery 31.6 ± 2.1 33.8 ±2 0.0004 2.4. Ethical considerations
Post operative day 1 30.3 ± 2.3 30.6 ±2 0.62
At discharge 33.1 ± 2.1 33.8 ± 1.5 0.15 The study was based on the ethical guidelines as given in the
Platelet count (x103/ml)
“Declaration of Helsinki” and was conducted after obtaining ethical
Pre-operative 246 ± 66 228 ± 42 0.25
After hemodilution 224 ± 62 - - clearance from the Institute’s ethical clearance committee and it
After surgery 195 ± 57 193 ± 33 0.87 was registered with Clinical Trial Registry of India (CTRI). Written
Post operative day 1 171 ± 39 144 ± 26 0.006 informed consent was obtained from all participants after
At discharge 245 ± 56 197 ± 27 0.0003
explaining them the study protocol, the benefits and risks of ANH
Prothrombin Time (s)
Pre-operative 14.5 ± 0.7 14.2 ± 0.6 0.84 and their right to withdraw from the study at their discretion at any
After hemodilution 16.6 ± 2 - - point of time.
After surgery 17.6 ± 2 17 ± 1.2 0.20
Post operative day 1 15.3 ± 0.5 16.4 ± 1 <0.00001
At discharge 14.2 ± 0.4 14.1 ± 0.3 0.45
3. Results

* Unpaired t-test, P < 0.05 was considered as statistically significant.

Table 2
Variation in hemodynamic parameters in ANH group.
During phlebotomy During surgery
Systolic BP (mm Hg) 122 ± 6 121 ± 7
Diastolic BP (mm Hg) 81 ± 4 79 ± 5
Heart rate (beats/min) 76 ± 6 78 ± 7
SpO2 (%) 98.6 ± 0.8 98.5 ± 1.1
BP¼ Blood pressure, SpO2 ¼ Oxygen saturation.
*P < 0.05 was considered as statistically significant.
reaction. Length of hospital stay was also calculated in both groups.
2.2. Outcome measures studied
The primary outcome measured was to study the need for
allogeneic blood transfusion in ANH group as compared to the
control group. The secondary outcomes that were measured
included the effect of ANH on the clinical outcome and length of
hospital stay in patients undergoing THR/TKR.
2.3. Statistical analysis
Data was collected about the haematological variables in both
ANH group and control group at various time points of follow up
period. The quantitative data was expressed as mean and standard
deviation (SD). Student t-test was used to compare any significant
difference in the mean value of the haematological variables be-
tween the two groups. The hemodynamic variables within the ANH
group were analyzed using the one-way analysis of variance of
ranks. The categorical data was expressed in frequency and chi-
square test was used for comparison of proportions. Statistical
tests were performed at a significance level of 0.05. The estimated
sample size for a two sample comparison regarding primary
outcome of allogeneic blood requirement at p < 0.05 and a power of
0.90 was determined to be 21 patients for each cohort.
Twenty five patients undergoing TKR/THR were assigned to the
ANH group and 25 patients to the control group. General charac-
teristics of the patients in both groups were comparable. Mean age
of the patients was 49 ± 9 years in the ANH group while it was
47 ± 12 years in the control group.
p value*
The variations in hemoglobin, hematocrit, platelet count, coa-
0.38 gulogram in both groups are shown in Table 1. Preoperative he-
0.10
0.30
moglobin was similar in both ANH and control groups (12.7 ± 0.7 vs
0.91 12.6 ± 0.6, p ¼ 0.56). Hemoglobin level after completion of surgery
was more in control group as compared to ANH group (11.1 ± 0.6 vs
10.4 ± 0.7; p ¼ 0.0002). Hemoglobin level decreased from
11.1 ± 0.6 g/dl at completion of surgery to 10 ± 0.6 g/dl at 24 h after
completion of surgery in control group. Prothrombin time index at
24 h after completion of surgery was 91.7 ± 3% in ANH group
whereas it was 85.9 ± 5.1% in the control group (p < 0.05). There
was no statistical difference in blood pressure, heart rate or oxygen
saturation during phlebotomy or during surgery in the ANH group
as shown in Table 2.
Four (16%) patients in the ANH group required allogeneic blood
transfusion as compared to 15 (60%) patients in the control group
(p ¼ 0.0001). Total estimated blood loss (sum total of intraoperative
and postoperative blood loss) was similar in ANH and control group
(1006 ± 221 ml vs 1036 ± 215 ml, p ¼ 0.63). Total time of surgery
was similar in both ANH and control group (189 ± 56 vs
184 ± 38 min, p ¼ 0.78).
Post operated complications were recorded in both the groups
as shown in Table 3. In ANH group, seven patients experienced a
total of eight post operative complications while 20 post operative
complications were observed in 16 patients from the control group.
This difference was statistically significant (7 vs 16, p ¼ 0.01).
Length of hospital stay was 10 ± 3 days in ANH group while it was
12 ± 3 days in the control group (p ¼ 0.06).
4. Discussion
A total of 167 cases of TKR or THR were performed during the
study period out of which 68 cases (40.7%) met the inclusion
criteria. Anemia was the most common reason for exclusion with
86 cases (51.4%) having a hemoglobin value of less than 12 g/dl.
ANH was not performed in one eligible patient because of poor
venous excess. One more eligible patient was excluded from the

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study because of uncontrollable hypertension during preoperative
period. The mean age of the patients undergoing ANH was 49 ± 9
years. Majority of the patients in the younger age group had a
primary diagnosis of avascular necrosis while osteoarthritis was
seen in older age group.
On comparing hemoglobin values of ANH and control group,
hemoglobin at completion of surgery was significantly higher
(p ¼ 0.0002) in control group (11.1 ± 0.6 g/dl) compared to ANH
group (10.4 ± 0.7 g/dl). This can be attributed to the additional
blood loss as a result of autologous blood being withdrawn after
induction of anesthesia in the ANH group. Mean post operative day
one hemoglobin levels were comparable in ANH group (10 ± 0.7 g/
dl) and in control group. Milam et al. suggested that in individuals
undergoing cardiac surgery, ANH results in improved blood
microcirculation.7 Moreover, the autologous blood kept at room
temperature preserves the platelet function and thus provides
platelets and clotting factors immedialtely after completion of
surgery. Both these factors might result in reduced postoperative
bleeding in patients undergoing ANH as is suggested by the lesser
drop in hemoglobin levels between completion of surgery and 24 h
after completion of surgery in ANH group as compared to the
control group.
Two inferences were drawn based upon the statistical analysis
of the coagulogram changes in both groups. Firstly, the coagulo-
gram was more deranged in ANH group as compared to control
group at completion of surgery which could be due to the addi-
tional blood collected in addition to the blood lost during the sur-
gical procedure. Hemodilution in itself is known to decrease the
effectiveness of clotting factors. Although the coagulogram was
more deranged in the ANH group but the mean PT, PTI, aPTT and
INR remained within normal range during all time points which is
in agreement with other studies.2,8,9 Dextran used for hemodilution
is known to have adverse influence on the clotting mechanism. It
decreases platelet adhesiveness, in addition it binds to the surface
of platelets, thus leading to increased surface electro negativity and
interfering with normal platelet interaction with the clotting fac-
tors.10 With the use of ringer lactate these adverse effects were
avoided. Secondly, although within normal limits, the coagulogram
was more deranged in control group, 24 h after completion of
surgery as compared to the ANH group. The result was statistically
significant (p < 0.05). As fresh clotting factors are returned to the
patient at wound closure in ANH there appears to be better
replenishment of the clotting factors in the ANH group.
Similar variation was observed with the platelet count, which
can be attributed to dual effect of return of viable platelets along
with the autologous blood transfused at completion of surgery, and
also due to lesser post operative blood loss in the ANH group.
However, the results were in argument with previous studies2,11
which found no significant effect of ANH on the platelet count.
Allogeneic blood transfusion results in immunosuppression in
the patient which is known as transfusion-associated immuno-
modulation.12,13 This immunosuppressive state has been shown to
result in increased incidence of postoperative bacterial infection.14
In our study post operative complication rate was observed in 64%
patients in the control group, while it was 28% in the ANH group,
which was statistically significant (p ¼ 0.01). In a study, it has been
seen that transfusion of autologous blood results in complement
system activation along with increased plasma levels of IL-6 in
healthy volunteers over a period of 7 days15 which may have a role
in reduced postoperative infection.
Similarly the length of hospital stay was 10 days in ANH group,
as compared to 12 days in the control group. Although it was sta-
tistically not significant (p ¼ 0.06), the reduction in the length of
hospital stay can be attributed to lesser post operative complication
rate and a better clinical outcome in patients who had undergone
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S847
ANH. The result was in agreement with the findings of Bennett
et al.2 who concluded that length of hospital stay is less in patients
undergoing ANH as compared to the control group. However Oishi
et al.11 found no difference in length of hospital stay between ANH
group and control group.
In our study allogeneic blood requirement decreased from 60%
in control group to 16% in the ANH group (p ¼ 0.001). This can be
attributed to lesser loss of RBC mass during the surgical procedure,
lesser postoperative blood loss along with the return of fresh
clotting factors and platelets at the completion of surgery. This is in
agreement in various past studies8,16,17 whereas it is in argument
with various other studies.1,6
The study had its limitations as well. Firstly the cut off age for
inclusion in the study was 65 years; hence 21.6% of the patients
were excluded from study because of age factor. Therefore efficacy
and safety of the procedure in this age group which forms a large
chunk of THR/TKR cases could not be studied. Secondly, throm-
boelastography and fibrinogen levels were not performed which
could have provided a better insight into the effect of ANH on the
coagulation profile of the patient.
ANH is still not routinely used in clinical practice in India. Per-
forming a successful ANH procedure requires an interdepartmental
approach. Similar effects of ANH can also be investigated in other
surgeries involving large blood loss. ANH also assumes greater
significance because of the increasing threat of newer emerging
pathogens which can be transmitted through allogeneic blood
transfusion.
5. Conclusions
ANH is a safe and efficacious procedure which can be of
increased value especially in developing countries like India where
chances of TTI are still high, and where there is high demand of
blood and acute shortage of blood in hospitals. Our study also re-
iterates the need for proper organization, planning and commu-
nication between surgeons, anesthesiologist and transfusion
specialists for its implementation. ANH in other elective surgeries
and emergency surgeries can also be studied.
Funding
This research received no specific grant from any funding
agency.
Author contributions
N.B. and G.K. were involved in study conception and design. N.B.,
SU.G. and SA.G conducted the study. N.B. and G.K. were involved in
data compilation, analysis and manuscript preparation. G.K, SU.G.
and SA.G. did the proof reading and corrections of manuscript. The
manuscript has been read and approved by all the authors.
Declaration of competing interest
The authors declare no conflicts of interest.
References
1. Zhou J. A review of the application of autologous blood transfusion. Braz J Med
Biol Res. 2016 Aug 1;49(9):5493. https://doi.org/10.1590/1414-431x20165493.
2. Bennett J, Haynes S, Torella F, Grainger H, McCollum C. Acute normovolemic
hemodilution in moderate blood loss surgery: a randomized controlled trial.
Transfusion. 2006;46:1097e1103. https://doi.org/10.1111/j.1537-
2995.2006.00857.x.
3. Rai S, Verma S, Yadav PK, Ahmad J, Yadav HK. Utility of acute normovolemic
hemodilution in major surgeries in rural area: a prospective comparative study
from North India. Anesth Essays Res. 2017;11(4):909e912. https://doi.org/
S848 N. Bansal et al. / Journal of Clinical Orthopaedics and Trauma 11 (2020) S844eS848

10.4103/aer.aer_86_17.
4. Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee
arthroplasty? Correct blood loss management should take hidden loss into
account. Knee. 2000;7:151e155. https://doi.org/10.1016/s0968-0160(00)
00047-8.
5. Gross GB. Estimating allowable blood loss: corrected for dilution. Anesthesi-
ology. 1983;58:277e280. https://doi.org/10.1097/00000542-198303000-
00016. Ali Algadiem E, Aleisa AA, Alsubaie HI, Buhlaiqah NR, Algadeeb JB,
Alsneini HA.
6. Ali Algadiem E, Aleisa AA, Alsubaie HI, Buhlaiqah NR, Algadeeb JB, Alsneini HA.
Blood loss estimation using gauze visual analogue. Trauma Mon. 2016 May
3;21(2), e34131. https://doi.org/10.5812/traumamon.34131.
7. Milam JD, Austin SF, Nihill MR, Keats AS, Cooley DA. Use of sufficient hemo-
dilution to prevent coagulopathies following surgical correction of cyanotic
heart disease. J Thorac Cardiovasc Surg. 1985;89:623e629.
8. Olsfanger D, Fredman B, Goldstein B, Shapiro A, Jedeikin R. Acute normovole-
mic hemodilution decreases postoperative allogeneic blood transfusion after
total knee replacement. Br J Anaesth. 1997;79:317e321. https://doi.org/
10.1093/bja/79.3.317.
9. Bennett SR. Perioperative autologous blood transfusion in elective total hip
prosthesis operations. Ann R Coll Surg Engl. 1994;76:95e98. https://doi.org/
10.1097/00132586-199412000-00057.
10. Weiss HJ. The effect of clinical dextran on platelet aggregation, adhesion, and
ADP release in man: in vivo and in vitro studies. J Lab Clin Med. 1967;69:37e46.
https://doi.org/10.1016/0002-9343(67)90180-5.
11. Oishi CS, D’Lima DD, Morris BA, Hardwick ME, Berkowitz SD, Colwell Jr CW.
Hemodilution with other blood reinfusion techniques in total hip arthroplasty.
Clin Orthop Relat Res. 1997;339:132e139. https://doi.org/10.1097/00003086-
199706000-00018.
12. Chang H, Hall GA, Geerts WH, Greenwood C, McLeod RS, Sher GD. Allogenic red
blood cell transfusion is an independent risk factor for the development of
postoperative bacterial infection. Vox Sang. 2000;78:13e18. https://doi.org/
10.1046/j.1423-0410.2000.7810013.x.
13. Fernandez MC, Gottlieb M, Menitove JE. Blood transfusion and postoperative
infection in orthopedic patients. Transfusion. 1992;32:318e322. https://
doi.org/10.1046/j.1537-2995.1992.32492263444.x.
14. Jensen LS, Andersen AJ, Christiansen PM, et al. Postoperative infection and
natural killer cell function following blood transfusion in patients undergoing
elective colorectal surgery. Br J Surg. 1992;79:513e516. https://doi.org/
10.1002/bjs.1800790613.
15. Frietsch T, Fessler H, Kirschfink M, Nebe T, Waschke KF, Lorentz A. Immune
response to autologous transfusion in healthy volunteers: WB versus packed
RBCs and FFP. Transfusion. 2001;41:470e476. https://doi.org/10.1046/j.1537-
2995.2001.41040470.x.
16. Naqash IA, Draboo MA, Lone AQ, Nengroo SH. Evaluation of acute normovo-
lemic hemodilution and autotransfusion in neurosurgical patients undergoing
excision of intracranial meningioma. J Anaesthesiol Clin Pharmacol. 2011;27:
54e58.
17. Goldberg J, Paugh TA, Dickinson TA, et al. Greater volume of acute normovo-
lemic hemodilution may aid in reducing blood transfusions after cardiac sur-
gery. Ann Thorac Surg. 2015;100(5):1581e1587. https://doi.org/10.1016/
j.athoracsur.2015.04.135.

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