Free
Pain Medicine  |   July 2003
Tolerance to Acute Isovolemic Hemodilution: Effect of Anesthetic Depth
Author Affiliations & Notes
  • Philippe Van der Linden, M.D., Ph.D.
    *
  • Stefan De Hert, M.D., Ph.D.
  • Nathalie Mathieu, M.D.
  • Françoise Degroote, M.D.
  • Denis Schmartz, M.D.
  • Haibo Zhang, M.D., Ph.D.
    §
  • Jean-Louis Vincent, M.D., Ph.D.
  • * Professor and Chairman, Department of Cardiac Anesthesia, CHU Charleroi. † Professor and Vice Chairman, Department of Anesthesiology, University Hospital Antwerp, Antwerp, Belgium. ‡ Adjunct Clinical Director, Department of Anesthesiology, § Professor, ∥ Professor and Chairman, Department of Intensive Care, Erasme University Hospital.
  • Received from the Departments of Anesthesiology and Intensive Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium.
Article Information
Pain Medicine
Pain Medicine   |   July 2003
Tolerance to Acute Isovolemic Hemodilution: Effect of Anesthetic Depth
Anesthesiology 7 2003, Vol.99, 97-104. doi:
Anesthesiology 7 2003, Vol.99, 97-104. doi:
ADEQUATE tissue oxygenation during acute normovolemic anemia is maintained by both an increase in cardiac output (CO) and an increase in tissue oxygen extraction. 1,2 The increase in CO is related to the reduction in blood viscosity resulting in increased venous return and decreased ventricular afterload 3,4 as well as an increased sympathetic stimulation of the heart. 5,6 Tissue oxygen extraction is increased at the systemic level by the redistribution of blood flow according to regional metabolic demand 7 and at the microcirculatory level by a better spatial and temporal distribution of the red blood cells into the capillary network. 8 When these compensatory mechanisms are exhausted, oxygen uptake starts to fall and becomes delivery dependent. 9,10 Under these conditions, tissue hypoxia develops as reflected by an abrupt rise in blood lactate concentrations. 10,11 The hemoglobin concentration (hemoglobin) at which this phenomenon occurs is defined as the critical hemoglobin. 9,10,12 
Recent acceptance of a lower transfusion trigger in the perioperative period has raised the question of the effects of anesthetic depth on the tolerance to acute isovolemic anemia. Anesthetic agents are known to decrease systemic oxygen uptake 13,14 in a dose-dependent way. This implies that a higher anesthetic level could be associated with a lower critical oxygen delivery (i.e.  , the value of oxygen delivery below which oxygen consumption becomes supply dependent). These apparent beneficial effects of a higher anesthetic depth on the tissue oxygen balance might be counterbalanced by the effects of anesthetic agents on the cardiovascular system. Indeed, anesthetic agents could alter the compensatory mechanisms implicated during isovolemic hemodilution, especially the CO response. This effect may be directly related to the vasodilating and negative inotropic effects of the anesthetic agents and/or indirectly related to the blunting of the sympathetic system activity. 15,16 
We hypothesized that the negative cardiovascular effects of anesthetic agents may exceed their effects on tissue metabolism, so that increasing the level of anesthesia may reduce tolerance to acute isovolemic anemia and increase the critical hemoglobin. We tested this hypothesis in a dog model of stepwise isovolemic hemodilution. In the first study, we assessed the effects of halothane, a volatile anesthetic with well-known cardiovascular depressant properties. 17,18 In a subsequent study, we evaluated the effects of ketamine, an agent with unique cardiovascular stimulant properties 19 related primarily to direct stimulation of central nervous system structures. 20,21 
Materials and Methods
Procedures
All experimental procedures were performed in accordance with the Belgian guidelines for care of laboratory animals and were approved by the animal research committee of the School of Medicine of the Free University of Brussels (Brussels, Belgium). Twenty-eight mongrel dogs were studied. In the first study, animals were anesthetized with halothane (n = 14; weight 23.8 ± 4.8 kg). After administration of intravenous thiopental 20 mg/kg, tracheal intubation was performed, and mechanical ventilation was started (Elema 900B; Siemens, Solna, Sweden) with air. Ventilatory frequency was set at 12 min−1, and tidal volume was adapted to maintain an arterial partial pressure of carbon dioxide (Paco2) of approximately 35 mmHg. Respiratory conditions remained unchanged until the end of the study. Anesthesia was maintained with halothane, anesthetic depth being adapted to the surgical stimulation of the experimental protocol (end-tidal minimum alveolar concentration [MAC] between 1.0 and 2.0). After completion of the surgical procedure, the dogs were randomly allocated to receive either 1.0 MAC halothane (0.96%; n = 7) or 1.5 MAC halothane (1.4%; n = 7). 22 
In a subsequent study, animals were anesthetized with ketamine (n = 14; 24.3 ± 4.7 kg). In this group, dogs were randomly allocated to receive ketamine either at low dose (an induction bolus of 5 mg/kg followed by a continuous infusion of 0.2 mg · kg−1· min−1; n = 7) or at high dose (an induction bolus of 10 mg/kg followed by a continuous infusion of 0.4 mg · kg−1· min−1; n = 7). After tracheal intubation was performed, controlled mechanical ventilation was started with respiratory conditions as described previously.
In both studies, animals received pancuronium bromide to facilitate controlled ventilation. This agent was given as an initial bolus of 0.1 mg/kg followed by hourly boluses of 1–2 mg.
Electrodes were attached to the four limbs for monitoring heart rate (HR). Two catheters (16-gauge; Becton Dickinson and Co., Rutherford, NJ) were inserted: one into a peripheral vein for fluids and drug infusion and one into the distal aorta through a femoral artery for monitoring of blood pressure and sampling of arterial blood. A pulmonary arterial catheter (Swan-Ganz catheter, model 93A-131-7F; Baxter Healthcare, Irvine, CA) was inserted through a jugular vein. A gas analyzer (Capnomac AGM 103; Datex, Helsinki, Finland) was inserted in the respiratory breathing system for monitoring of end-tidal carbon dioxide tension (Petco2) and halothane concentration. Exhaled gases were directed through a mixing chamber for sampling to measure mixed expired oxygen fraction (Feo2) using a paramagnetic method (semirapid oxygen analyzer, model 500D PK; Morgan Co., Chatam, United Kingdom). The oxygen analyzer and the capnometer were calibrated before each experiment. Expired minute ventilation was measured with a spirometer (model Magtrak II, London, United Kingdom) located proximal to the mixing chamber. Respiratory circuit was carefully checked for air leakage before each experiment.
A splenectomy was performed through a midline laparotomy to prevent autotransfusion. To compensate for insensible fluid losses, the dogs received an intravenous infusion of 0.9% sodium chloride at a rate of 10 ml/kg during the splenectomy and 1 ml · kg−1· h−1thereafter, until the end of the experiment. Body temperature was maintained at 36–38°C throughout the study using warming blankets and humidified heated gases.
Heart rate, arterial pressure, and pulmonary arterial pressure were monitored continuously (Sirecust; Siemens AG, Erlangen, Germany) and recorded together with Petco2and Feo2(model 8000S; Gould Electronique, Ballainvilliers, France). Zero pressure was set at the midchest level of the animal.
Heart rate and intravascular pressures, including mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), pulmonary arterial occlusion pressure, and right atrial pressure, were measured at end-expiration from the paper trace. Feo2and Petco2were measured from the paper trace over 1 min. Expired volume was measured over the same period. CO was measured with the thermodilution technique (module E 2261/A; Siemens AG) by repeated injections of 10 ml cold (<5°C) dextrose, 5%, in water. Each injection was started at the end of expiration. 23 Three to five measurements, with a variability of less than 10%, were averaged for each CO measurement. Immediately thereafter, arterial and mixed venous blood samples were withdrawn for measurement of blood gas tensions (ABL 2; Radiometer, Copenhagen, Denmark). Hemoglobin and oxygen saturation were measured using a CO oximeter calibrated for dog's blood (OSM 3; Radiometer). Each sample was analyzed twice, and the two values were averaged. Arterial blood lactate concentration (lactate) was measured enzymatically using an automated analyzer (Kontron, Basel, Switzerland).
Cardiac index (CI), stroke index (SI), systemic vascular resistance (SVR), left ventricular stroke work index, and arterial and mixed venous oxygen content were calculated using standard formulae. Oxygen delivery (Do2) was calculated from CO measurements and arterial oxygen content and indexed for weight. Oxygen consumption (V̇o2) was calculated from measured Feo2and minute ventilation, using the appropriate mass balance equation and accounting for the difference between inspired and expired nitrogen fraction, indexed for weight. 24 Oxygen extraction (O2ER) was obtained by dividing V̇o2by Do2.
Baseline measurements were performed 30 min after completion of splenectomy. Each animal was then slowly hemodiluted by repeated withdrawals of 5-ml/kg aliquots of arterial blood simultaneously replaced by the same volume of 6% hydroxyethyl starch, 200/0.5 (Haes Steril 6%; Fresenius AG, Bad Hombourg, Germany). After each exchange procedure, a 10-min period was allowed to achieve a new steady state defined by a stable MAP, Petco2, and Feo2. The exchange procedure was continued until the animal could no longer maintain a stable arterial pressure. Death followed shortly thereafter, with the animal still anesthetized.
Statistical Analysis
In each animal, critical Do2was determined from a plot of V̇o2versus  Do2using the dual lines regression method. 25 Critical Do2was defined as the point of intersection of the two best-fit regression lines as determined by a least sum of squares technique. Critical O2ER was calculated as the ratio of V̇o2/Do2at critical point. Critical Do2was also determined in each animal using the same dual regression lines analysis from a plot of lactate versus  Do2. The critical value of hemoglobin was determined using the same mathematical analysis from a plot of V̇o2versus  hemoglobin (hemoglobin from V̇o2) and from a plot of lactate versus  hemoglobin (hemoglobin from lactate). Figures 1 and 2illustrate the V̇o2–Do2, lactate–Do2, V̇o2–hemoglobin, and lactate–hemoglobin relationships that were obtained in each dog in the halothane and ketamine studies.
Fig. 1. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the 1.0 MAC halothane (Halo 1.0, left  ) and 1.5 MAC halothane (Halo 1.5, right  ) groups.
Fig. 1. Representative examples of the (top 
	) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom 
	) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the 1.0 MAC halothane (Halo 1.0, left 
	) and 1.5 MAC halothane (Halo 1.5, right 
	) groups.
Fig. 1. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the 1.0 MAC halothane (Halo 1.0, left  ) and 1.5 MAC halothane (Halo 1.5, right  ) groups.
×
Fig. 2. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the low-dose ketamine (Ket low, left  ) and high-dose ketamine (Ket high, right  ) groups.
Fig. 2. Representative examples of the (top 
	) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom 
	) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the low-dose ketamine (Ket low, left 
	) and high-dose ketamine (Ket high, right 
	) groups.
Fig. 2. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the low-dose ketamine (Ket low, left  ) and high-dose ketamine (Ket high, right  ) groups.
×
The hemoglobin–Do2relationship was also analyzed in each animal by determining the polynomial that best fit the data. Equations of these polynomials were used to determine Do2values corresponding to fixed hemoglobin values. This allowed for comparison of the Do2response to progressive hemodilution between the two anesthetic dosages in the halothane and the ketamine study.
For both halothane and ketamine, sample size was calculated to detect a difference in critical hemoglobin of 40% between the two anesthetic dosages with a power of 0.8 and an α of 0.05.
Hemodynamic and respiratory variables obtained at baseline and at the experimental point closest to critical Do2with the two anesthetic dosages were compared using a two-way analysis of variance, followed by pairwise comparisons using a Tukey honest significance difference post hoc  test. Data obtained at critical point in the two anesthetic levels were compared using the Mann–Whitney U test. In each group, the hemoglobin–Do2relationship was compared between the two anesthetic dosages using a two-way analysis of variance for repeated measurements. Because anesthetic depth between both agents could not be compared, no statistical analysis was performed between data obtained with the two anesthetic agents.
All values are expressed as mean ± SD. A P  value less than 0.05 was considered statistically significant.
Results
Halothane Anesthesia
Hemodynamic and Oxygen-derived Variables.
In all animals, acute isovolemic hemodilution resulted in a significant decrease in MAP and in SVR (table 1). In the 1.0 MAC halothane group, CI increased, mainly through an increase in SI. In the 1.5 MAC halothane group, neither CI nor SI increased. As compared to 1.0 MAC, 1.5 MAC halothane anesthesia resulted in a lower HR and MAP, a higher pulmonary arterial occlusion pressure, and a lower CI, SI, and left ventricular stroke work index. Between the two anesthetic dosages, there was a significantly different response to acute hemodilution for CI and SI. In all dogs, acute isovolemic hemodilution resulted in a decrease in mixed venous oxygen saturation. Do2decreased but V̇o2remained constant as O2ER increased (table 1). Just before the critical point, hemoglobin tended to be higher, and V̇o2to be lower, in the 1.5 MAC halothane group.
Table 1. Hemodynamic and O2-derived Variables in the Halothane Groups
Image not available
Table 1. Hemodynamic and O2-derived Variables in the Halothane Groups
×
Table 1. (continued)
Image not available
Table 1. (continued)
×
Data at Critical Point.
Critical Do2was significantly lower in the 1.5 MAC halothane group (table 2). This was due to a lower critical V̇o2as critical O2ER was not significantly different between the two groups. Critical Do2obtained from lactate was also significantly lower in the 1.5 MAC halothane group. Lactate at the critical point was not different in the 1.5 MAC halothane and 1.0 MAC halothane groups. Critical hemoglobin obtained through either V̇o2or lactate was significantly higher in the 1.5 MAC halothane group than in the 1.0 MAC halothane group. V̇o2at critical hemoglobin was lower in the 1.5 MAC halothane group than in the 1.0 MAC halothane group (3.6 ± 0.3 and 4.5 ± 1.2 ml · min−1· kg−1, respectively;P  < 0.05). Lactate at critical hemoglobin was not different between the two groups (1.5 MAC halothane: 2.8 ± 1.1 mm/l; 1.0 MAC halothane: 2.0 ± 1.0 mm/l.
Table 2. Data at Critical Point in the Halothane Groups
Image not available
Table 2. Data at Critical Point in the Halothane Groups
×
Hemoglobin–Do2Relationship.
With the two anesthetic concentrations, isovolemic hemodilution resulted in a progressive decrease in Do2(fig. 3, top  ). Do2changes in response to the stepwise decrease in hemoglobin concentration were significantly different among the two halothane concentrations.
Fig. 3. (Top  ) Hemoglobin–oxygen delivery (Do2) relationship in the two halothane groups during stepwise hemodilution. Stars  = halothane 1.0 MAC group;squares  = halothane 1.5 MAC group. (Bottom  ) Hemoglobin–Do2relationship in the two ketamine groups during stepwise hemodilution. Stars  = ketamine low-dose group;squares  = ketamine high-dose group.
Fig. 3. (Top 
	) Hemoglobin–oxygen delivery (Do2) relationship in the two halothane groups during stepwise hemodilution. Stars 
	= halothane 1.0 MAC group;squares 
	= halothane 1.5 MAC group. (Bottom 
	) Hemoglobin–Do2relationship in the two ketamine groups during stepwise hemodilution. Stars 
	= ketamine low-dose group;squares 
	= ketamine high-dose group.
Fig. 3. (Top  ) Hemoglobin–oxygen delivery (Do2) relationship in the two halothane groups during stepwise hemodilution. Stars  = halothane 1.0 MAC group;squares  = halothane 1.5 MAC group. (Bottom  ) Hemoglobin–Do2relationship in the two ketamine groups during stepwise hemodilution. Stars  = ketamine low-dose group;squares  = ketamine high-dose group.
×
Ketamine Anesthesia
Hemodynamic and Oxygen-derived Variables.
In all animals, acute isovolemic hemodilution resulted in a significant decrease in MAP (table 3). In the low-dose ketamine group, CI increased, mainly through an increase in SI. SVR decreased. In the high-dose ketamine group, neither CI nor SI increased. As compared to low-dose ketamine, high-dose ketamine resulted in a lower HR and MPAP, a higher SVR, and a lower CI, SI, and left ventricular stroke work index (table 3). Between the two anesthetic dosages, there was a significantly different response to acute hemodilution for HR, CI, SI, and SVR. In all dogs, acute isovolemic hemodilution resulted in a decrease in arterial pH and mixed venous oxygen saturation. Do2decreased but V̇o2remained constant as O2ER increased (table 3). Just before the critical point, hemoglobin concentration tended to be higher and V̇o2was significantly lower in the high-dose ketamine group.
Table 3. Hemodynamic and O2-derived Variables in the Ketamine Groups
Image not available
Table 3. Hemodynamic and O2-derived Variables in the Ketamine Groups
×
Table 3. (continued)
Image not available
Table 3. (continued)
×
Data at Critical Point.
Critical Do2was significantly lower in the high-dose ketamine group (table 4). This was due to a lower critical V̇o2as critical O2ER was not significantly different between the two groups. Critical Do2obtained from lactate was also significantly lower in the high-dose ketamine group. Critical hemoglobin obtained from V̇o2was significantly higher in the high-dose ketamine group. V̇o2at critical hemoglobin was significantly lower in the high-dose ketamine group than in the low-dose ketamine group (4.4 ± 1.2 and 6.0 ± 0.9 ml · min−1· kg−1, respectively;P  < 0.05). Critical hemoglobin obtained from lactate tended to be higher in the high-dose ketamine group, although the difference did not reach statistical significance. Lactate at critical hemoglobin was not different between the two groups (high-dose ketamine: 1.7 ± 0.7 mm/l; low-dose ketamine: 1.8 ± 0.8 mm/l.
Table 4. Data at Critical Point in the Ketamine Groups
Image not available
Table 4. Data at Critical Point in the Ketamine Groups
×
Hemoglobin–Do2Relationship.
With the two anesthetic concentrations, isovolemic hemodilution resulted in a progressive decrease in Do2(fig. 3, bottom  ). Do2changes in response to the stepwise decrease in hemoglobin concentration were significantly different among the two ketamine dosages.
Discussion
Increased anesthetic depth obtained with either halothane or ketamine resulted in a decreased tolerance to acute isovolemic anemia, as reflected by an increase in critical hemoglobin, the value of hemoglobin below which V̇o2becomes supply dependent. With both agents, the increase in critical hemoglobin at the higher anesthetic level was related to a complete blunting of the CO response usually observed during isovolemic hemodilution. 1–3 Indeed, CI and SI increased only with the lower dose of each agent but not with the higher one.
These results were observed with two anesthetic agents having quite different cardiovascular properties. 17–21 The blunting of the CO response with the higher halothane concentration occurred in the presence of higher filling pressures and, despite a lower SVR, reflecting the negative inotropic properties of this agent. A depressant effect of halothane on the sympathetic system could also be implicated. 26,27 In the ketamine study, the blunting of the CO response with the higher anesthetic dosage also seemed to be related to a direct depression of the myocardial function, as reflected by the lower left ventricular stroke work index. This phenomenon occurred despite the effects of this agent on the sympathetic system, as evident from the better maintenance of MAP and SVR during the progressive hemodilution. Although ketamine possesses cardiostimulatory effects through an increase in sympathetic outflow, it also presents direct myocardial depressant properties. 28,29 In conditions associated with increased sympathetic stimulation, the direct effects of ketamine on the myocardium could exceed its sympathomimetic properties, resulting in global depressant hemodynamic effects. 30,31 
Our results may have been affected by the concomitant use of other agents such as thiopental and pancuronium. Thiopental, however, was used only in the halothane study and was administered at least 2 h before the experimental protocol. Therefore, it seems unlikely that this drug would have influenced our observations. Pancuronium was used to facilitate mechanical ventilation. This agent, which decreases vagolytic tone and increases sympathetic tone, 32 could have different effects on animals anesthetized with halothane or with ketamine. However, within each anesthetic study, it probably had little influence on our results, as the dose of muscle relaxant used was similar in animals receiving the low and the high anesthetic dosages.
Medium-molecular-weight hydroxyethyl starch was used for the hemodilution protocol as this kind of solution has been shown to produce stable plasma volume expansion. 33 Because of the high chloride concentration in the diluent of the solution, its uses may be associated with the development of metabolic acidosis, as reflected by the decrease in arterial pH observed in both the halothane and the ketamine studies. This effect, however, was similar in animals receiving the low and the high anesthetic dosages.
In this protocol of progressive hemodilution, with both agents, critical Do2was significantly lower in the animals receiving the higher anesthetic dosage. This resulted from lower oxygen requirements as indicated by a lower critical V̇o2. This could be in part related to the dose-dependent negative inotropic properties of halothane and ketamine, resulting in a decreased myocardial oxygen demand. Central body temperature tended to be lower in the animal receiving the higher anesthetic dosage, despite the use of warming blankets and humidified heated gases, A difference in less than 1° in central temperature, however, could hardly explain the marked difference in oxygen consumption between the two anesthetic dosages in the halothane and ketamine studies. Indeed, hypothermia decreases whole body metabolic rate by approximately 8% by Celsius degrees. 34 The lower central body temperature observed in the animals receiving the higher anesthetic dosage could be a result of the decreased perfusion but could also reflect the effects of anesthesia on the body's thermoregulation system in a cold operating room environment. 35 
During the hemodilution protocol, Do2decreased progressively in both the halothane and the ketamine studies as a result of the blunting of the CO response in our anesthetized animals (fig. 3). This is in contrast with previous works reporting that when hematocrit is reduced, systemic oxygen transport capacity first increases slightly, reaches a peak at approximately 30% hematocrit, and does not fall below control levels as long as the hematocrit remains above 20%. 36,37 The Do2response to hemodilution could have been predicted with halothane but was more surprising for ketamine. This agent has a dual effect on the cardiovascular system, the balance of its indirect stimulant properties and the direct myocardial depressant properties being altered by concentration and time as shown in figure 3.
We took a number of precautions to ensure the validity of our observations. V̇o2was determined from expired gas analysis, whereas Do2was calculated from thermodilution CO and blood gas analysis, so that there was no mathematical coupling of the data. A similar protocol has been used by Cain et al.  9 in evaluating the effects of isovolemic anemia on critical Do2in pentobarbital-anesthetized dogs. Determining critical Do2“by eye,” this author evaluated that the hematocrit value for which V̇o2became Do2-dependent was around 10%. In the current study, critical hemoglobin was obtained from both V̇o2and lactate determinations. Both approaches demonstrated similar hemoglobin values that were consistently larger in dogs anesthetized with the higher anesthetic dosage. Interestingly, critical Do2and critical hemoglobin values obtained from lactate measurements were in agreement with those derived from V̇o2measurements, confirming the usefulness of this parameter to detect the development of tissue hypoxia during profound anemia. 10,11,38 
To test the hypothesis that anesthesia can decrease tolerance to acute isovolemic hemodilution, we used two anesthetic agents with well-defined cardiovascular and metabolic effects. In the current study, when the depth of anesthesia was increased, the depressant effects of halothane and ketamine on the cardiovascular system outweighed their possible beneficial effects on tissue metabolism, whatever their effects on the sympathetic system. Our observations may not be directly applicable to other inhaled anesthetics, especially desflurane. However, newer halogenated anesthetics also have negative inotropic properties 39,40 that can decrease the CO response associated with acute isovolemic hemodilution. Although isoflurane has been shown to maintain CO better than halothane, Schou et al.  41 demonstrated in the pig that isoflurane induced a dose-dependent decrease in CO response during profound normovolemic hemodilution. Several studies using fentanyl–isoflurane–N2O, 42 fentanyl–droperidol–N2O, 43 or fentanyl–midazolam 44 anesthetic-based protocols also reported a blunting of the CO response during isovolemic hemodilution in man. A parasympathetic stimulation related to the central vagal stimulation induced by some opioids such as fentanyl 45 could be responsible for a lack of increase in HR, thereby contributing to a decrease in the CO response. Therefore, a decreased tolerance to acute isovolemic anemia when anesthesia is deepened could be relevant for other anesthetic agents with cardiovascular depressant properties. Our observations emphasize the importance of carefully titrating the level of anesthesia and monitoring the cardiovascular response in patients with moderate to severe anemia.
References
Weiskopf RB, Viele MK, Feiner J, Kelley S, Lieberman J, Noorani M, Leung JM, Fisher DM, Murray WR, Toy P, Moore MA: Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA 1998; 279: 217–21Weiskopf, RB Viele, MK Feiner, J Kelley, S Lieberman, J Noorani, M Leung, JM Fisher, DM Murray, WR Toy, P Moore, MA
Lieberman JA, Weiskopf RB, Kelley SD, Feiner J, Noorani M, Leung JM, Toy P, Viele MK: Critical oxygen delivery in conscious humans is less than 7.3 ml O2· kg−1· min−1. A nesthesiology 2000; 92: 407–13Lieberman, JA Weiskopf, RB Kelley, SD Feiner, J Noorani, M Leung, JM Toy, P Viele, MK
Fowler NO, Holmes JC: Blood viscosity and cardiac output in acute experimental anemia. J Appl Physiol 1975; 39: 453–6Fowler, NO Holmes, JC
Doss DN, Estafanous FG, Ferrario CM, Brum JM, Murray PA: Mechanism of systemic vasodilation during normovolemic hemodilution. Anesth Analg 1995; 81: 30–4Doss, DN Estafanous, FG Ferrario, CM Brum, JM Murray, PA
Glick G, Plauth WH, Braunwald EB: Role of the autonomic nervous system in the circulatory response to acutely induced anemia in unanesthetized dogs. J Clin Invest 1964; 43: 2112–24Glick, G Plauth, WH Braunwald, EB
Hatcher JD, Chiu LK, Jennings DB: Anemia as a stimulus to aortic and carotid chemoreceptors in the cat. J Appl Physiol 1978; 44: 696–702Hatcher, JD Chiu, LK Jennings, DB
Tuman KJ: Tissue oxygen delivery: The physiology of anemia. Anesthesiol Clin North Am 1990; 8: 451–69Tuman, KJ
Messmer K: Blood rheology factors and capillary blood flow, Tissue Oxygen Utilization. Edited by Gutierrez G, Vincent J-L. Berlin, Springer-Verlag, 1991, pp 103–13
Cain SM: Oxygen delivery and uptake in dogs during anemic and hypoxic hypoxia. J Appl Physiol 1977; 42: 228–34Cain, SM
Van der Linden P, De Groote F, Mathieu N, Willaert P, Schmartz D, Vincent J-L: Critical haemoglobin concentration in anaesthetized dogs: Comparison of two plasma substitutes. Br J Anaesth 1998; 81: 556–62Van der Linden, P De Groote, F Mathieu, N Willaert, P Schmartz, D Vincent, J-L
Cain SM: Appearance of excess lactate in anesthetized dogs during anemic and hypoxic hypoxia. Am J Physiol 1965; 209: 604–8Cain, SM
van Bommel J, Siegmund M, Henny P, Trouwborst A, Ince C: Critical hematocrit in Intestinal tissue oxygenation during severe normovolemic hemodilution. A nesthesiology 2001; 94: 152–60van Bommel, J Siegmund, M Henny, P Trouwborst, A Ince, C
Theye RA: Oxygen uptake during light halothane anesthesia in man. A nesthesiology 1964; 25: 627–33Theye, RA
Viale J-P, Annat G, Bertrand O, Thouverez B, Hoen JP, Motin J: Continuous measurement of pulmonary gas exchange during general anaesthesia in man. Acta Anaesthesiol Scand 1988; 32: 691–7Viale, J-P Annat, G Bertrand, O Thouverez, B Hoen, JP Motin, J
Roizen MF, Horrigan RW, Frazer BM: Anesthetic doses blocking adrenergic (stress) and cardiovascular responses to incision-MAC BAR. A nesthesiology 1981; 54: 390–8Roizen, MF Horrigan, RW Frazer, BM
Daniel M, Weiskopf RB, Noorani M, Eger EI: Fentanyl augments the blockade of the sympathetic response to incision (MAC-BAR) produced by desflurane and isoflurane. A nesthesiology 1998; 88: 43–9Daniel, M Weiskopf, RB Noorani, M Eger, EI
Eger EI, Smith NT, Stoeltink RK, Cullen DJ, Kadis LB, Witcher CE: Cardiovascular effects of halothane in man. A nesthesiology 1970; 32: 396–403Eger, EI Smith, NT Stoeltink, RK Cullen, DJ Kadis, LB Witcher, CE
Sonntag H, Merin RG, Donath U, Radke J, Schenk D: Myocardial metabolism and oxygenation in man awake and during halothane anesthesia. A nesthesiology 1979; 51: 204–10Sonntag, H Merin, RG Donath, U Radke, J Schenk, D
White PF, Way WL, Trevor AJ: Ketamine: Its pharmacology and therapeutic uses. A nesthesiology 1982; 56: 119–36White, PF Way, WL Trevor, AJ
Ivankovich AD, Miletich DJ, Reimann C: Cardiovascular effects of centrally administered ketamine in goats. Anesth Analg 1974; 53: 924–33Ivankovich, AD Miletich, DJ Reimann, C
Chodoff P: Evidence for a central adrenergic action of ketamine. Anesth Analg 1972; 51: 247–50Chodoff, P
Steffey EP, Howland DJ: Potency of enflurane in dogs: Comparison with halothane and isoflurane. Am J Vet Res 1978; 39: 573–7Steffey, EP Howland, DJ
Daper A, Parquier J-N, Preiser J-C, Contempre B, Vincent J-L: Timing of cardiac output measurements during mechanical ventilation. Acute Care 1989; 12: 113–6Daper, A Parquier, J-N Preiser, J-C Contempre, B Vincent, J-L
De Backer D, Roman A, Van der Linden P, Armistead C, Schiltz G, Vincent J-L: The effects of balloon filling into the inferior vena cava on the VO2/DO2 relationship. J Crit Care 1992; 7: 167–73De Backer, D Roman, A Van der Linden, P Armistead, C Schiltz, G Vincent, J-L
Samsel RW, Schumacker PT: Determination of the critical O2 delivery from experimental data: Sensitivity to error. J Appl Physiol 1988; 64: 2074–82Samsel, RW Schumacker, PT
Muldoon SM, Vanhoutte PM, Lorenz RR, Van Dyke RA: Venomotor changes caused by halothane acting on the sympathetic nerves. A nesthesiology 1975; 43: 41–8Muldoon, SM Vanhoutte, PM Lorenz, RR Van Dyke, RA
Bosnjak ZJ, Seagard JL, Wu A, Kampine JP: The effects of halothane on sympathetic ganglionic transmission. A nesthesiology 1982; 57: 473–9Bosnjak, ZJ Seagard, JL Wu, A Kampine, JP
Horwitz LD: Effects of intravenous anesthetic agents on left ventricular function in dogs. Am J Physiol 1977; 232: H44–8Horwitz, LD
Diaz FA, Bianco JA, Bello A, Beer N, Uelarde H, Izquierdo JP, Jaen R: Effects of ketamine on canine cardiovascular function. Br J Anaesth 1976; 48: 941–5Diaz, FA Bianco, JA Bello, A Beer, N Uelarde, H Izquierdo, JP Jaen, R
Weiskopf RB, Bogetz MS, Roizen MF, Reid IA: Cardiovascular and metabolic sequelae of inducing anesthesia with ketamine or thiopental in hypovolemic swine. A nesthesiology 1984; 60: 214–9Weiskopf, RB Bogetz, MS Roizen, MF Reid, IA
Waxman K, Shoemaker WC, Lipmann M: Cardiovascular effects of anesthetic induction with ketamine. Anesth Analg 1980; 59: 355–8Waxman, K Shoemaker, WC Lipmann, M
Belmont MR, Scott RPF: Muscle relaxants and the cardiovascular system, Cardiac Anesthesia, 4th edition. Edited by Kaplan JA, Reich DL, Konstadt SN. Philadelphia, WB Saunders, 1999, pp 635–55
Treib J, Baron JF: An international view of hydroxyethyl starches. Intensive Care Med 1999; 25: 258–68Treib, J Baron, JF
Sessler DI: Temperature monitoring, Anesthesia, 3rd edition. Edited by Miller RD. New York, Churchill Livingstone, 1990, pp 1227–42
Bissonnette B, Nebbia SP: Hypothermia during anesthesia: Physiology and effects of anesthetics on thermoregulation. Anesthesiol Clin North Am 1994; 12: 409–24Bissonnette, B Nebbia, SP
Hint H: The pharmacology of dextran and the physiological background for the clinical use of Rheomacrodex and Macrodex. Acta Anesthesiologica Belg 1968; 19: 119–38Hint, H
Messmer K, Sunder-Plasmann L, Klövekorn WP, Holper K: Circulatory significance of hemodilution: Rheological changes and limitations. Adv Microcirc 1972; 4: 1–77Messmer, K Sunder-Plasmann, L Klövekorn, WP Holper, K
Widness JA, Lowe LS, Bell EF, Burmeister LF, Mock DM, Kistard JA, Bard H: Adaptive responses during anemia and its correction in lambs. J Appl Physiol 2000; 88: 1397–406Widness, JA Lowe, LS Bell, EF Burmeister, LF Mock, DM Kistard, JA Bard, H
Hettrick DA, Pagel PS, Warltier DC: Desflurane, sevoflurane and isoflurane impair canine left ventricular-arterial coupling and mechanical efficiency. A nesthesiology 1996; 85: 403–13Hettrick, DA Pagel, PS Warltier, DC
De Hert S, Van der Linden P, ten Broecke PW, Vermeylen KT, Rodrigus IE, Stockman BA: Effects of desflurane and sevoflurane on length-dependent regulation of myocardial function in coronary surgery patients. A nesthesiology 2001; 95: 357–63De Hert, S Van der Linden, P ten Broecke, PW Vermeylen, KT Rodrigus, IE Stockman, BA
Schou H, Perez De Sa V, Larsson A, Roscher R, Kongstad L, Werner O: Hemodilution significantly decreases tolerance to isoflurane-induced cardiovascular depression. Acta Anesthesiol Scand 1997; 41: 218–28Schou, H Perez De Sa, V Larsson, A Roscher, R Kongstad, L Werner, O
Ickx B, Rigolet M, Van der Linden P: Cardiovascular and metabolic response to acute normovolemic anemia: Effects of anesthesia. A nesthesiology 2000; 93: 1011–6Ickx, B Rigolet, M Van der Linden, P
Rosberg B, Wulff K: Hemodynamics following normovolemic hemodilution in elderly patients. Acta Anesthesiol Scand 1981; 25: 402–6Rosberg, B Wulff, K
Spahn DR, Seifert B, Pasch T, Schmid ER: Effects of chronic beta-blockade on compensatory mechanisms during acute isovolaemic haemodilution in patients with coronary artery disease. Br J Anaesth 1997; 78: 381–5Spahn, DR Seifert, B Pasch, T Schmid, ER
Reitan JA, Stengert KB, Wymore ML, Martucci RW: Central vagal control of fentanyl-induced bradycardia during halothane anesthesia. Anesth Analg 1978; 57: 31–6Reitan, JA Stengert, KB Wymore, ML Martucci, RW
Fig. 1. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the 1.0 MAC halothane (Halo 1.0, left  ) and 1.5 MAC halothane (Halo 1.5, right  ) groups.
Fig. 1. Representative examples of the (top 
	) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom 
	) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the 1.0 MAC halothane (Halo 1.0, left 
	) and 1.5 MAC halothane (Halo 1.5, right 
	) groups.
Fig. 1. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the 1.0 MAC halothane (Halo 1.0, left  ) and 1.5 MAC halothane (Halo 1.5, right  ) groups.
×
Fig. 2. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the low-dose ketamine (Ket low, left  ) and high-dose ketamine (Ket high, right  ) groups.
Fig. 2. Representative examples of the (top 
	) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom 
	) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the low-dose ketamine (Ket low, left 
	) and high-dose ketamine (Ket high, right 
	) groups.
Fig. 2. Representative examples of the (top  ) oxygen consumption (V̇o2)–oxygen delivery (Do2), lactate–Do2and (bottom  ) V̇o2–hemoglobin, and lactate–hemoglobin relationships in the low-dose ketamine (Ket low, left  ) and high-dose ketamine (Ket high, right  ) groups.
×
Fig. 3. (Top  ) Hemoglobin–oxygen delivery (Do2) relationship in the two halothane groups during stepwise hemodilution. Stars  = halothane 1.0 MAC group;squares  = halothane 1.5 MAC group. (Bottom  ) Hemoglobin–Do2relationship in the two ketamine groups during stepwise hemodilution. Stars  = ketamine low-dose group;squares  = ketamine high-dose group.
Fig. 3. (Top 
	) Hemoglobin–oxygen delivery (Do2) relationship in the two halothane groups during stepwise hemodilution. Stars 
	= halothane 1.0 MAC group;squares 
	= halothane 1.5 MAC group. (Bottom 
	) Hemoglobin–Do2relationship in the two ketamine groups during stepwise hemodilution. Stars 
	= ketamine low-dose group;squares 
	= ketamine high-dose group.
Fig. 3. (Top  ) Hemoglobin–oxygen delivery (Do2) relationship in the two halothane groups during stepwise hemodilution. Stars  = halothane 1.0 MAC group;squares  = halothane 1.5 MAC group. (Bottom  ) Hemoglobin–Do2relationship in the two ketamine groups during stepwise hemodilution. Stars  = ketamine low-dose group;squares  = ketamine high-dose group.
×
Table 1. Hemodynamic and O2-derived Variables in the Halothane Groups
Image not available
Table 1. Hemodynamic and O2-derived Variables in the Halothane Groups
×
Table 1. (continued)
Image not available
Table 1. (continued)
×
Table 2. Data at Critical Point in the Halothane Groups
Image not available
Table 2. Data at Critical Point in the Halothane Groups
×
Table 3. Hemodynamic and O2-derived Variables in the Ketamine Groups
Image not available
Table 3. Hemodynamic and O2-derived Variables in the Ketamine Groups
×
Table 3. (continued)
Image not available
Table 3. (continued)
×
Table 4. Data at Critical Point in the Ketamine Groups
Image not available
Table 4. Data at Critical Point in the Ketamine Groups
×