Hetastarch is used for intravascular volume expansion in cardiac surgery. Studies show conflicting effects of intraoperative hetastarch administration on postoperative bleeding. Hetastarch was routinely used for volume expansion during cardiovascular surgeries at our institution until its use was discontinued intraoperatively. We performed a retrospective chart review on patients undergoing primary coronary artery bypass grafting, valve repair or replacement requiring cardiopulmonary bypass (n = 444), 234 of which received intraoperative hetastarch and 210 did not. There was no difference in demographics, cardiac surgery, or cardiopulmonary bypass duration between the two groups. Blood loss for 0-4 h postoperatively was 377 +/- 244 mL in the group not receiving hetastarch compared with 515 +/- 336 mL in the group that received hetastarch (P < 0.001). For 0-24 h postoperatively, blood loss was 923 +/- 473 mL versus 1,283 +/- 686 mL in the absence and presence of hetastarch, respectively (P < 0.001). Allogeneic transfusion requirements (cryoprecipitate, fresh frozen plasma, and platelets) were larger in the hetastarch group (all P < 0.001). Nearly all (99%) patients in the hetastarch group received less than the manufacturer's recommended dose (20 mL/kg) of hetastarch. IMPLICATIONS: Our large retrospective study suggests that intraoperative use of hetastarch in primary cardiac surgery with cardiopulmonary bypass may increase bleeding and transfusion requirements. A large prospective study is needed to determine if intraoperative administration of hetastarch should be avoided during cardiovascular surgery.
"There have also have been small studies associating the use of HES with intracranial bleeding and coagulopathy in the setting of subarachnoid hemorrhage (Damon et al. 1987; Knutson et al. 2000). The mechanisms causing this acquired coagulopathy include qualitative platelet dysfunction , decreases in Factor VIII/von Willebrand's factor complexes (sometimes referred to as " Acquired von "
[Show abstract][Hide abstract] ABSTRACT: Intraoperative intravascular volume expansion with hydroxyethyl starch-based colloids is thought to be associated with an increased risk of post-craniotomy hemorrhage. Evidence for this association is limited. Associations between resuscitation with hydroxyethyl starch and risk of repeat craniotomy for hematoma evacuation were examined.
Using a retrospective cohort of neurosurgical patients at Duke University Medical Center between March 2005 and March 2012, patient characteristics were compared between those who developed post-craniotomy hemorrhage and those who did not.
A total of 4,109 craniotomy procedures were analyzed with 61 patients having repeat craniotomy for post-operative hemorrhage (1.5%). The rate of reoperation in the group receiving 6% High Molecular Weight Hydroxyethyl Starch (Hextend(®)) was 2.6 vs. 1.3% for patients that did not receive hetastarch (P = 0.13). The reoperation rate for those receiving 6% hydroxyethyl Starch 130/0.4 (Voluven(®)) was 1.4 vs. 1.6% in patients not receiving Voluven (P = 0.85).
In this retrospective cohort, intra-operative hydroxyethyl starch was not associated with an increased risk of post-craniotomy hemorrhage.
[Show abstract][Hide abstract] ABSTRACT: Coagulopathy associated with massive operative blood loss is an intricate, multicellular and multifactorial event. Massive bleeding can either be anticipated (during major surgery with high risk of bleeding) or unexpected. Management requires preoperative risk evaluation and preoperative optimization (discontinuation or modification of anticoagulant drugs, prophylactic coagulation therapy). Intraoperatively, the causal diagnosis of the complex pathophysiology of massive bleeding requiring rapid and specific coagulation management is critical for the patient's outcome. Treatment and transfusion algorithms, based on repeated and timely point-of-care coagulation testing and on the clinical judgment, are to be encouraged. The time lapse for reporting results and insufficient identification of the hemostatic defect are obstacles for conventional laboratory coagulation tests. The evidence is growing that rotational thrombelastometry or modified thrombelastography are superior to routine laboratory tests in guiding intraoperative coagulation management. Specific platelet function tests may be of value in platelet-dependent bleeding associated e.g. with extracorporeal circulation, antiplatelet therapy, inherited or acquired platelet defects. Therapeutic approaches include the use of blood products (red cell concentrates, platelets, plasma), coagulation factor concentrates (fibrinogen, prothrombin complex, von Willebrand factor), pharmacological agents (antifibrinolytic drugs, desmopressin), and local factors (fibrin glue). The importance of normothermia, normovolemia, and homeostasis for hemostasis must not be overlooked. The present article reviews pathomechanisms of coagulopathy in massive bleeding, as well as routine laboratory tests and viscoelastic point-of-care hemostasis monitoring as the diagnostic basis for therapeutic interventions.
[Show abstract][Hide abstract] ABSTRACT: Objectives Understand the timing, extent, and the immediate goals for the initial fluid resuscitation in trauma victims, individualized to specific patients. Review the factors influencing choice of fluid for the initial and ongoing resuscitation. Discuss factors influencing the decision for initiating transfusion therapy, choice of blood products, immediate and delayed risks and benefits of transfusion therapy. Become familiar with the current state of therapies intended for the most severely injured patients, including recombinant factor VIIa and massive blood transfusion protocols. Initial evaluation of an acutely volume-depleted trauma patient will include a primary and secondary survey according to Advanced Trauma Life Support® protocol, an estimate of blood volume deficit (Table 6.1), rate of the ongoing blood loss, and an evaluation of cardiopulmonary reserve and coexisting hepatic or renal dysfunction . The overriding priority of trauma management is to maintain or restore vital organ perfusion and oxygenation above critical levels at an early stage, and to restore perfusion and oxygenation to normal levels as soon as it becomes appropriate. This is best achieved by stopping the bleeding and repleting intravascular volume. Perfusion pressure and oxygenated blood flow to vital organs are important determinants of outcome. Management priorities in an acutely bleeding trauma patient include ventilation and oxygenation (see Chapter 2), assessment of perfusion, estimation of volume replacement requirements, establishment or verification of adequate intravenous (IV) access (see Chapter 4), measurement of blood pressure, placement of electrocardiogram (ECG), pulse oximeter and capnograph, and laboratory studies.
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