Blood Conservation Strategies in a Patient Undergoing Excision of Cerebellar Hemangioblastoma: Clinical Dilemmas and Decision Making
By Adriana Martin, MD
Kevin Piepsey, MD
Shobana Rajan, MD
Shobana Rajan, MD
Von Hippel Lindau Syndrome (VHL) is manifested by a variety of benign and malignant tumors, including hemangioblastomas, pheochromocytoma and renal cell carcinoma (RCC). Brain hemangioblastomas are capillary vessel-rich benign neoplasms that can affect 60 to 80% of patients with VHL.1 Surgery is usually indicated due to peritumoral edema and can be associated with significant bleeding requiring blood transfusion and leading to increase in postoperative morbidity.2
Homologous blood transfusion is not a risk free procedure and can lead to infections, anaphylaxis, hemolytic reactions and lung injury. Oftentimes, anesthesiologists will face situations where blood transfusion is contra-indicated (Jehovah's Witnesses that refuse transfusion) or not recommended (potential kidney transplant recipients). Blood conservation strategies are being introduced to our practice with the aim of reducing the exposure to allogenic blood. Acute normovolemic hemodilution (ANH) and cell salvage are two intra-operative strategies that have been proved to reduce the need for blood transfusion.3-4
In this case, we will discuss the decision-making process regarding blood conservation strategies for a patient with cerebellar hemangioblastoma scheduled for retrosigmoidal craniectomy.
A 58-year-old female with past medical history of VHL presented for left side craniectomy for a cerebellar hemangioblastoma that was causing significant mass effect. She also had a history of RCC status post bilateral nephrectomy and anemia secondary to chronic kidney disease (Baseline Hemoglobin of 10 g/dL, on Darbopoetin injections regularly). She was on home hemodialysis six times per week and was on the list for kidney transplant. The patient was advised to avoid blood products transfusion to reduce the risk of alloimmunization. She was seen at our pre-anesthesia clinic to discuss available blood conservation strategies. We had to make a decision weighing the risk of cerebral ischemia due to bleeding and anemia with the risk of the effect of blood transfusion on her future kidney transplant.
Alternative options for blood transfusion were discussed. ANH was discussed, but we decided to not use it for this patient because of her chronic anemia and impaired renal function with the risk for volume overload. Cell salvage was another option raised and the patient didn’t have any contraindications. The patient was already receiving optimized treatment for her chronic anemia. In this setting, it was decided to proceed with surgery with the use of cell saver and to use transfusion only as a last resort. Tranexamic acid was another potential option in these patients but data is limited with respect to its use in craniotomy patients.
Retrosigmoidal craniectomy was successfully performed and the estimated blood loss was 50 mL. There were no bleeding complications and blood conservation strategy was not needed on the day of surgery. Hemoglobin remained stable and she was discharged home on post-operative day four.
Anesthesiologists face patients requiring blood transfusion almost on a daily basis and approximately half of all blood transfused occurs in surgical patients.5 Although it is commonly performed, it is not a risk free procedure. Transfusion-associated complications include risk of transmitting infectious agents, anaphylactic reactions, hemolytic reactions, injury to the lungs (Transfusion-Related Acute Lung Injury, TRALI), volume overload (Transfusion-Associated Circulatory Overload, TACO), as well as, electrolytes imbalances.
This case raised multiple questions regarding blood conservation techniques that could be used to help avoid allogenic transfusion:
- What are the currently available intraoperative blood conversation strategies?
- What is acute normovolemic hemodilution? What are its indications and contra-indications?
- What are the indications and contra-indications for cell salvage?
- What is the role of tranexamic acid in neurosurgery?
Blood conservation strategies exist to reduce the patients exposure to allogenic blood transfusion and the potential risks associated with it. Although ANH and cell salvage have been proven to be effective blood conservation strategies, they also have contra-indications and risks that we should be familiar with.
ANH entails the removal of blood from a patient after induction of anesthesia to reduce to red cell mass of the blood lost during surgery. Euvolemia is maintained by crystalloid or colloid replacement and the blood removed is re-transfused at the end of the surgery. The idea is that with the hemodilution we decrease the number of red blood cells lost during surgery. Additionally, it reinfuses back fresh whole blood, containing viable platelets and coagulation factors, decreasing the risk of dilutional thrombocytopenia and coagulopathy. A meta-analysis showed that ANH produces a 26% decrease in the exposure to allogenic blood, but this is only significant when blood loss exceeds 1L.3 It has been proven to be safe and an effective way of reducing need for blood transfusion in neurosurgery patients undergoing excision of intracranial meningioma.6 The risk associated with ANH include volume overload and this technique is best avoided in patients with impaired renal and cardiac functions. Baseline anemia with hemoglobin less than 11g/dL is a contra-indication. The amount of blood removed usually varies between one to three units and is calculated by a formula that considers estimated blood volume and hemoglobin. At the same time, the anesthesiologist should also consider the hemodynamics of the patient while the blood is being removed in the beginning of the surgery.
Blood salvage, also called intraoperative auto-transfusion, is the use of a cell saver machine to separate, wash, and concentrate salvaged red blood cells aspirated from the surgical field to be reinfused into the patient. It is recommended for surgeries where there is a high likelihood of significant blood loss and it has the ability to rapidly provide large quantities of autologous blood. Cell salvage has been shown to be effective in reducing the need for allogenic blood transfusion with lower rate of adverse events.4 Relative contraindications are bacterial infections and active malignancy, and in these cases the decision on whether to use it or not should be made in a case-by-case basis. Because blood salvage replaces only red blood cells, there is a potential risk of dilutional coagulopathy, especially in cases with significant blood loss. Other potential complications include TACO, bacterial contamination and air embolism.
The use of procoagulant products that inhibit fibrinolysis is another option to decrease bleeding. Antifibrinolytics like tranexamic acid have been studied in procedures with high-risk for major bleeding and have been shown to reduce blood loss and need for transfusion. Two meta-analysis studied the use of tranexamic acid in spine surgery and showed that it effectively reduces blood loss and transfusions.7-8 Concerns with the use of antifibrinolytic therapy is the potential risk of prothrombotic effect, but scientific data has suggested the relative safety of these agents regarding thromboembolic complications.9 Another concern is that tranexamic acid has been shown to increase the risk of seizures. Unfortunately, there is insufficient data evaluating the use of tranexamic acid in patient undergoing craniotomy for tumor resection. A small study showed promising results with less bleeding, less transfusions and better surgical field hemostasis, but large trials are needed to confirm these findings.10
When scheduled for elective procedures, patients with preoperative anemia of chronic kidney disease should have their hemoglobin optimized with iron and erythropoietin. Although the case went successfully without the need for blood conservation techniques, anesthesiologists should always be prepared for complications and should be familiar with these techniques that can be used intraoperatively to help reduce the exposure to allogenic blood. The goal for high-risk surgeries entails assessing the patient in the preoperative period for bleeding risk and preoperative hemoglobin, discuss best strategies for blood management intraoperatively, as well as, techniques that can be used to minimize blood loss.
- Jagannathan J, Lonser RR, Smith R, et al. Surgical management of cerebellar hemangioblastomas in patients with von Hippel–Lindau disease. J Neurosurg. 2008 Feb; 108(2): 210-222.
- Brundi E, Schodel P, Ullrich OW, et al. Surgical resection of sporadic and hereditary hemangioblastoma: Our 10-year experience and a literature review. Surg Neurol. 2014; 5: 138.
- Zhou X, Zhang C, Wang Y, et al. Preoperative Acute Normovolemic Hemodilution for Minimizing Allogeneic Blood Transfusion: A Meta-Analysis. Anesth Analg.2015 Dec;121(6):1443-55.
- Carless PA, Henry DA, Moxey AJ, et al. Cell salvage for minimising perioperative allogeneic blood transfusion.Cochrane Database Syst Rev.2010 Apr 14;(4).
- Chen A, Trivedi, AN, Jiang L, et al. Hospital Blood Transfusion Patterns During Major Noncardiac Surgery and Surgical Mortality. Medicine. 2015; 94(32):e1342.
- Nagash IA, Draboo, MA, Lone AQ, et al. Evaluation of acute normovolemic hemodilution and autotransfusion in neurosurgical patients undergoing excision of intracranial meningioma. J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):54-8.
- Gill JB, Chin Y, Levin A, et al. The use of antifibrinolytic agents in spine surgery. A meta-analysis. J. Bone Joint Surg Am. 2008 Nov;90(11):2399-407.
- Li G, Sun TW, Luo G, et al. Efficacy of antifibrinolytic agents on surgical bleeding and transfusion requirements in spine surgery: a meta-analysis. Eur Spine J. 2017;26(1):140.
- Levy JH, Koster A, Quinones QJ, et al. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology. 2018 Mar;128(3):657-670.
- Hooda B, Chouban RS, Rath GP, et al. Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma. J. Clin Neurosci.2017 Jul;41:132-138.