Actu anaesth. scund. 1979, 23, 242-247
Regional Lung Function Following Hip Ar throplasty and Preoperative Normovolemic Hemodilution B. ROSBERG and K . WULFF Departments of Anesthesiology, Clinical Physiology and Orthopedic Surgery, Malmo General Hospital, Malmo, Sweden
The effect of preoperative normovolemic hemodilution with dextran 70 as dilutional agent on postoperative regional lung function was evaluated in patients undergoing hip arthroplasty in the lateral decubitus position. The major part of the surgical blood loss of these patients was replaced with the received autologous blood. The results obtained were compared to changes in a group of patients in whom the operative bleeding was replaced with bank blood. Regional lung function, as studied with Xe'33 radiospirometry, is not negatively influenced by the hemodilution technique. In both groups a reduction in perfusion, ventilation and volume of ventilated alveoli was revealed postoperativcly in the lung that was dependent during surgery, probably caused by impaired ventilation of this lung and peroperatively induced microembolism. A more rapid normalization was found in the preoperatively hernodiluted patients. T h e reduced volume of bank blood transfused to these patients and/or a protective effect of the preoperatively infused dextran on the microembolism evoked by the surgical trauma might explain this difference between the groups studied. Received 18 September, accepted f o r publication 10 October 1978
& SCHLO1973, BLAISDELL Total hip replacement surgery gives rise to a fusion (BLAISDELL rather large and constant blood loss. Tech- BOHM 1973, PELTIER1969, SAFARet al. 1972, niques to reduce the need for bank blood WEBB 1969). I t has also been demonstrated include preoperative normovolemic hemo- following major orthopedic surgery, such as 1971, GRESHAM dilution (KLOVEKORN et al. 1974, MESSMER total hip arthroplasty (DANDY 1975, MESSMER & SUNDER-PLASSMAN 1974). et al. 1971, MODEet al. 1974). An important This technique implies that immediately cause of this is microembolism, with accumubefore surgery a plasma substitute is infused lation of platelets and fibrin in the lungs 1972). Prophylactic treatment with during simultaneous blood letting, and the (SALDEEN dextran has been shown to reduce the received autologous blood is then used to amount of trapped fibrin in animals with replace operative blood loss (KLOVEKORN et al. induced intravascular coagulation (DIFFANG 1974). The high risk of postoperative thromet al. 1976). boembolic complications following hip surgery This investigation was done to study the ( H ~ ~ ~ e 1976) t a l makesdextran,withits . wellpossibly beneficial influence of the preknown antithrombotic properties (GRUBER et operatively administered dextran and deal. 1975) a suitable dilutional agent. Pulmonary dysfunction is a common and creased transfusion of donor blood on postwell-documented consequence of trauma, operative changes of regional lung function, shock, sepsis, burns and massive blood trans- using Xe' 3 3 radiospirometry. 0001-5172/79/030242-06$02.50/0
0 1979 The Scandinavian
Socirty of Anaesthesiologists
REGIONAL LUNG FUNCTION FOLLOWING HEMODILUTION
MATERIAL AND METHODS
243
synstigmine (2.5 mg) were given to reverse the neuromuscular block and, if necessary, nalorphine (Nalorphin," AB Leo, Sweden) to counteiact the respiratory depression.
I'd ietrts Patients suffering from coxarthrosis and undergoing total hip arthroplasty of the Brunswik type, performed Technique of hemodilutioti. After the induction of aneswith the patient in the lateral decubitus position, were thesia, blood was withdrawn via a venous or arterial studied. Patients presenting with rheumatoid arthritis line (Donafixo, Viggo AB, Sweden) into bottles conor anemia (hemoglobin concentration < 120 g/l) as taining acid-citrate-dextrose solution. Simultaneously well as those with a history of cardiopulmonary disease and a t the same speed, an equivalent volume of or pathological EGG-tracings, pulmonary X-ray or dextran 70 (Macrodex 6% in saline@,Pharmacia AB, blood-gas analysis were excluded from the study. Sweden) was infused. The bled volume was calculated The patients were divided into two groups. Operaaccording to a formula given by BOURKE& SMITH tive blood loss in the first group (control group: 2 (1974) to reach a hematocrit value in the range 25females, 5 males; mean age 66 13 years) was replaced 30%. The upper dosage limit recommended for by homologous bank blood. In the second group (hemodextran 70 (1.5 g/kg body weight) was not exceeded, dilution group: 4 females, 4 males; mean age 66 11 which in same cases reduced the shed volume. years) the patients underwent preoperative hemoThe autologous blood collected in this way was used dilution and the major part of the operative blood loss to replace operative bleeding; additional bank blood was replaced by autologous blood. was transfused only when necessary to maintain The patients in the control group received in addition normovolemia. to bank blood 0.5 1 dextran 70 (Macrodex 6% in saline@', Pharmacia AB, Sweden) on the day of operaMeasurements. The operative blood loss was estimated tion, infused slowly from the start of surgery during a by measuring the blood in a suction apparatus, and by period of 6-8 h, followed by another 0.5 1 during the weighing sponges and drapes. Total bleeding included second postoperative day, according to the thromboblood collected in suction drains in the postoperative cmbolic prophylactic routine used in the Department period as well. of Orthopedic Surgery (AHLBERG et al. 1968). The radiospirometric technique for measuring regThus, the essential differences between the two ional lung function described by MIORNER(1968) was groups were: slightly modified. Four-field radiospirometric equipI . In the group treated by preoperative hemodilution, ment (ARBORELIUS JR. et al. 1970) was used, and the all dextran was administered immediately before the detectors were positioned on the ventral side of the surgical procedure. chest with the patient in the supine position. Each of 2. Preoperative hemodilution increased the degree and the four scintillation detectors covered a quadrant of duration of hemodilution compared with the control the lungs - two apical and two basal (MIORNER1968). group, as determined by hematocrit values (AHLBEKG The level between the apical and the basal fields was et al. 1977). the same for the four measurements at the fourth 3. The major part of the surgical blood loss in the intercostal space. The radiospirometric measurements preoperatively hemodiluted group was replaced by started with a rapid injection of 0.2-0.3 mC autologous blood. The volume of transfused bank (dissolved in saline) into the central venous catheter. blood was thus greatly reduced as compared to the The patient was breathing spontaneously and the air control group. was exhaled through a mouth-piece and a tube. The distribution of the lung perfusion between the four lung Methods fields was estimated from the simultaneously recorded Anesthesia. A neurolep tic analgesic technique was used counting rates (Qr), excluding injection artifacts. in all patients. It was induced by droperidol (Dridol", During room-air respiration the background level was AB Leo, Sweden) 15 mg, followed by inhalation of a assumed, and after a normal relaxed expiration, the N,O/O, mixture. Fentanyl (Leptanal", AB Leo, patient was connected to a spirograph (Lundia, AB Sweden) was then slowly injected until the patient did Kifa, Sweden), and inhaled xenon'33-enriched air. not respond to external stimuli. Intubation was The volume of the spirograph gas mixture was kept performed using a cuffed endotracheal tube after an constant by addition of 100°A 0,. The counting rates injection of pancuronium bromide (Pavulon@,Organ- over the four lung fields a t the second or third inhalaon, Holland) 6 mg. Additional doses of fentanyl (0.1tion were chosen as representative of the distribution 0.2 mg/h) were given during the operation. The of the ventilation (V,). The counting rates a t an endpatients were mechanically ventilated (Engstrom model expiratory moment, when stable counting rates were 300, LKB Medical AB, Sweden) with a 2 : I N , 0 / 0 , reached, were considered representative of the distrimixture. Frequency of respiration was 20, and the bution of the alveolar volume (FRC,) (MIORNER minute volume was calculated according to ENGSTROM 1968). The distribution of the vital capacity was & HERZOC(1959). Atropine sulphate (1.0 mg) and estimated after a maximal exhalation and inhalation.
244
B . ROSBERG AND K . WULFF
Functional residual capacity (FRC) was determined with the patient in a supine position, using a continuous N z wash-out technique during oxygen breathing. Correction was made for nitrogen dissolved in the body when calculating the functional reqidual capacity (BOUHUYS et al. 1956). Radiospirometries and FRC-determinations were done preoperatively and repeated postoperatively 1, 20 and 72-96 h after termination of the operation.
CONTROL
1
L
HEMODILUTIO N
I
Symbols and Abbreviations
FRC Functional residual capacity (lung volume at relaxed end-expiratory level in liters. Determined using N z wash-out technique). FRC, Regional ventilated lung volume as a percentage of total lung volume at relaxed endexpiratory level. V, Regional ventilation as a percentage of total ventilation. Qr Regional perfusion as a percentage of total perfusion to the lung. VC, Regional vital capacity as a percentage of total vital capacity. “Total” here means the added function of all four lung fields. In the statistical analysis of the results, calculatioun were made of the mean, standard deviation and standard error of the mean as well as the mean of the difference and standard error of the mean difference. Comparisons were carried out with the use of Student’s t-test for paired observations or, between group3, for means of two samples. Degrees of significance were marked as follows, and indicate the change of the recorded values as compared with the preoperative measurements: * 0.05>P>0.01; * * 0.01 >PzO.OOI; * * * P
Regional Lung Function Following Hip Ar throplasty and Preoperative Normovolemic Hemodilution B. ROSBERG and K . WULFF Departments of Anesthesiology, Clinical Physiology and Orthopedic Surgery, Malmo General Hospital, Malmo, Sweden
The effect of preoperative normovolemic hemodilution with dextran 70 as dilutional agent on postoperative regional lung function was evaluated in patients undergoing hip arthroplasty in the lateral decubitus position. The major part of the surgical blood loss of these patients was replaced with the received autologous blood. The results obtained were compared to changes in a group of patients in whom the operative bleeding was replaced with bank blood. Regional lung function, as studied with Xe'33 radiospirometry, is not negatively influenced by the hemodilution technique. In both groups a reduction in perfusion, ventilation and volume of ventilated alveoli was revealed postoperativcly in the lung that was dependent during surgery, probably caused by impaired ventilation of this lung and peroperatively induced microembolism. A more rapid normalization was found in the preoperatively hernodiluted patients. T h e reduced volume of bank blood transfused to these patients and/or a protective effect of the preoperatively infused dextran on the microembolism evoked by the surgical trauma might explain this difference between the groups studied. Received 18 September, accepted f o r publication 10 October 1978
& SCHLO1973, BLAISDELL Total hip replacement surgery gives rise to a fusion (BLAISDELL rather large and constant blood loss. Tech- BOHM 1973, PELTIER1969, SAFARet al. 1972, niques to reduce the need for bank blood WEBB 1969). I t has also been demonstrated include preoperative normovolemic hemo- following major orthopedic surgery, such as 1971, GRESHAM dilution (KLOVEKORN et al. 1974, MESSMER total hip arthroplasty (DANDY 1975, MESSMER & SUNDER-PLASSMAN 1974). et al. 1971, MODEet al. 1974). An important This technique implies that immediately cause of this is microembolism, with accumubefore surgery a plasma substitute is infused lation of platelets and fibrin in the lungs 1972). Prophylactic treatment with during simultaneous blood letting, and the (SALDEEN dextran has been shown to reduce the received autologous blood is then used to amount of trapped fibrin in animals with replace operative blood loss (KLOVEKORN et al. induced intravascular coagulation (DIFFANG 1974). The high risk of postoperative thromet al. 1976). boembolic complications following hip surgery This investigation was done to study the ( H ~ ~ ~ e 1976) t a l makesdextran,withits . wellpossibly beneficial influence of the preknown antithrombotic properties (GRUBER et operatively administered dextran and deal. 1975) a suitable dilutional agent. Pulmonary dysfunction is a common and creased transfusion of donor blood on postwell-documented consequence of trauma, operative changes of regional lung function, shock, sepsis, burns and massive blood trans- using Xe' 3 3 radiospirometry. 0001-5172/79/030242-06$02.50/0
0 1979 The Scandinavian
Socirty of Anaesthesiologists
REGIONAL LUNG FUNCTION FOLLOWING HEMODILUTION
MATERIAL AND METHODS
243
synstigmine (2.5 mg) were given to reverse the neuromuscular block and, if necessary, nalorphine (Nalorphin," AB Leo, Sweden) to counteiact the respiratory depression.
I'd ietrts Patients suffering from coxarthrosis and undergoing total hip arthroplasty of the Brunswik type, performed Technique of hemodilutioti. After the induction of aneswith the patient in the lateral decubitus position, were thesia, blood was withdrawn via a venous or arterial studied. Patients presenting with rheumatoid arthritis line (Donafixo, Viggo AB, Sweden) into bottles conor anemia (hemoglobin concentration < 120 g/l) as taining acid-citrate-dextrose solution. Simultaneously well as those with a history of cardiopulmonary disease and a t the same speed, an equivalent volume of or pathological EGG-tracings, pulmonary X-ray or dextran 70 (Macrodex 6% in saline@,Pharmacia AB, blood-gas analysis were excluded from the study. Sweden) was infused. The bled volume was calculated The patients were divided into two groups. Operaaccording to a formula given by BOURKE& SMITH tive blood loss in the first group (control group: 2 (1974) to reach a hematocrit value in the range 25females, 5 males; mean age 66 13 years) was replaced 30%. The upper dosage limit recommended for by homologous bank blood. In the second group (hemodextran 70 (1.5 g/kg body weight) was not exceeded, dilution group: 4 females, 4 males; mean age 66 11 which in same cases reduced the shed volume. years) the patients underwent preoperative hemoThe autologous blood collected in this way was used dilution and the major part of the operative blood loss to replace operative bleeding; additional bank blood was replaced by autologous blood. was transfused only when necessary to maintain The patients in the control group received in addition normovolemia. to bank blood 0.5 1 dextran 70 (Macrodex 6% in saline@', Pharmacia AB, Sweden) on the day of operaMeasurements. The operative blood loss was estimated tion, infused slowly from the start of surgery during a by measuring the blood in a suction apparatus, and by period of 6-8 h, followed by another 0.5 1 during the weighing sponges and drapes. Total bleeding included second postoperative day, according to the thromboblood collected in suction drains in the postoperative cmbolic prophylactic routine used in the Department period as well. of Orthopedic Surgery (AHLBERG et al. 1968). The radiospirometric technique for measuring regThus, the essential differences between the two ional lung function described by MIORNER(1968) was groups were: slightly modified. Four-field radiospirometric equipI . In the group treated by preoperative hemodilution, ment (ARBORELIUS JR. et al. 1970) was used, and the all dextran was administered immediately before the detectors were positioned on the ventral side of the surgical procedure. chest with the patient in the supine position. Each of 2. Preoperative hemodilution increased the degree and the four scintillation detectors covered a quadrant of duration of hemodilution compared with the control the lungs - two apical and two basal (MIORNER1968). group, as determined by hematocrit values (AHLBEKG The level between the apical and the basal fields was et al. 1977). the same for the four measurements at the fourth 3. The major part of the surgical blood loss in the intercostal space. The radiospirometric measurements preoperatively hemodiluted group was replaced by started with a rapid injection of 0.2-0.3 mC autologous blood. The volume of transfused bank (dissolved in saline) into the central venous catheter. blood was thus greatly reduced as compared to the The patient was breathing spontaneously and the air control group. was exhaled through a mouth-piece and a tube. The distribution of the lung perfusion between the four lung Methods fields was estimated from the simultaneously recorded Anesthesia. A neurolep tic analgesic technique was used counting rates (Qr), excluding injection artifacts. in all patients. It was induced by droperidol (Dridol", During room-air respiration the background level was AB Leo, Sweden) 15 mg, followed by inhalation of a assumed, and after a normal relaxed expiration, the N,O/O, mixture. Fentanyl (Leptanal", AB Leo, patient was connected to a spirograph (Lundia, AB Sweden) was then slowly injected until the patient did Kifa, Sweden), and inhaled xenon'33-enriched air. not respond to external stimuli. Intubation was The volume of the spirograph gas mixture was kept performed using a cuffed endotracheal tube after an constant by addition of 100°A 0,. The counting rates injection of pancuronium bromide (Pavulon@,Organ- over the four lung fields a t the second or third inhalaon, Holland) 6 mg. Additional doses of fentanyl (0.1tion were chosen as representative of the distribution 0.2 mg/h) were given during the operation. The of the ventilation (V,). The counting rates a t an endpatients were mechanically ventilated (Engstrom model expiratory moment, when stable counting rates were 300, LKB Medical AB, Sweden) with a 2 : I N , 0 / 0 , reached, were considered representative of the distrimixture. Frequency of respiration was 20, and the bution of the alveolar volume (FRC,) (MIORNER minute volume was calculated according to ENGSTROM 1968). The distribution of the vital capacity was & HERZOC(1959). Atropine sulphate (1.0 mg) and estimated after a maximal exhalation and inhalation.
244
B . ROSBERG AND K . WULFF
Functional residual capacity (FRC) was determined with the patient in a supine position, using a continuous N z wash-out technique during oxygen breathing. Correction was made for nitrogen dissolved in the body when calculating the functional reqidual capacity (BOUHUYS et al. 1956). Radiospirometries and FRC-determinations were done preoperatively and repeated postoperatively 1, 20 and 72-96 h after termination of the operation.
CONTROL
1
L
HEMODILUTIO N
I
Symbols and Abbreviations
FRC Functional residual capacity (lung volume at relaxed end-expiratory level in liters. Determined using N z wash-out technique). FRC, Regional ventilated lung volume as a percentage of total lung volume at relaxed endexpiratory level. V, Regional ventilation as a percentage of total ventilation. Qr Regional perfusion as a percentage of total perfusion to the lung. VC, Regional vital capacity as a percentage of total vital capacity. “Total” here means the added function of all four lung fields. In the statistical analysis of the results, calculatioun were made of the mean, standard deviation and standard error of the mean as well as the mean of the difference and standard error of the mean difference. Comparisons were carried out with the use of Student’s t-test for paired observations or, between group3, for means of two samples. Degrees of significance were marked as follows, and indicate the change of the recorded values as compared with the preoperative measurements: * 0.05>P>0.01; * * 0.01 >PzO.OOI; * * * P
