Does intraoperative hetastarch administration increase blood loss and transfusion requirements after cardiac surgery?
ABSTRACT 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.
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ABSTRACT: /st>Infusion of 5% human albumin (HA) and 6% hydroxyethyl starch 130/0.4 (HES) during cardiac surgery expand circulating volume to a greater extent than crystalloids and would be suitable for a restrictive fluid therapy regimen. However, HA and HES may affect blood coagulation and could contribute to increased transfusion requirements. /st>We randomly assigned 240 patients undergoing elective cardiac surgery to receive up to 50 ml kg(-1) day(-1) of either HA, HES, or Ringer's lactate (RL) as the main infusion fluid perioperatively. Study solutions were supplied in identical bottles dressed in opaque covers. The primary outcome was chest tube drainage over 24 h. Blood transfusions, thromboelastometry variables, perioperative fluid balance, renal function, mortality, intensive care unit, and hospital stay were also assessed. /st>The median cumulative blood loss was not different between the groups (HA: 835, HES: 700, and RL: 670 ml). However, 35% of RL patients required blood products, compared with 62% (HA) and 64% (HES group; P=0.0003). Significantly, more study solution had to be administered in the RL group compared with the colloid groups. Total perioperative fluid balance was least positive in the HA group [6.2 (2.5) litre] compared with the HES [7.4 (3.0) litre] and RL [8.3 (2.8) litre] groups (P<0.0001). Both colloids affected clot formation and clot strength and caused slight increases in serum creatinine. /st>Despite equal blood loss from chest drains, both colloids interfered with blood coagulation and produced greater haemodilution, which was associated with more transfusion of blood products compared with crystalloid use only.BJA British Journal of Anaesthesia 10/2013; 112(2). DOI:10.1093/bja/aet348 · 4.35 Impact Factor
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ABSTRACT: The effects of hydroxyethyl starch on bleeding after cardiopulmonary bypass were determined. A meta-analysis was performed of postoperative blood loss in randomized clinical trials of hydroxyethyl starch versus albumin for fluid management in adult cardiopulmonary bypass surgery. Impacts of hydroxyethyl starch molecular weight and molar substitution were assessed. Randomized trials directly comparing different hydroxyethyl starch solutions were also included. Eighteen trials with 970 total patients were included. Compared with albumin, hydroxyethyl starch increased postoperative blood loss by 33.3% of a pooled SD (95% confidence interval, 18.2%-48.3%; P < .001). Risk of reoperation for bleeding was more than doubled by hydroxyethyl starch (relative risk, 2.24; 95% confidence interval, 1.14-4.40; P = .020). Hydroxyethyl starch increased transfusion of red blood cells by 28.4% of a pooled SD (95% confidence interval, 12.2%-44.6%; P < .001), of fresh-frozen plasma by 30.6% (95% confidence interval, 8.0%-53.1%; P = .008), and of platelets by 29.8% (95% confidence interval, 3.4%-56.2%; P = .027). None of these effects differed significantly between hydroxyethyl starch 450/0.7 and 200/0.5. Insufficient data were available for hydroxyethyl starch 130/0.4 versus albumin; however, no significant differences were detected in head-to-head comparisons of hydroxyethyl starch 130/0.4 with 200/0.5. Albumin improved hemodynamics. There were no differences in fluid balance, ventilator time, intensive care unit stay, or mortality. Hydroxyethyl starch increased blood loss, reoperation for bleeding, and blood product transfusion after cardiopulmonary bypass. There was no evidence that these risks could be mitigated by lower molecular weight and substitution.The Journal of thoracic and cardiovascular surgery 05/2012; 144(1):223-30. DOI:10.1016/j.jtcvs.2012.04.009 · 3.99 Impact Factor
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ABSTRACT: Das hämodynamische Monitoring und die Differenzialtherapie mittels adäquater Volumensubstitution sowie positiv-inotroper und vasoaktiver Substanzen sind die Grundpfeiler der postoperativen intensivmedizinischen Behandlung von kardiochirurgischen Patienten. Ziel der S3-Leitlinie ist es, die Empfehlungen zum Monitoring und zur Therapie evidenzbasiert zu prüfen sowie Zielkriterien hierfür festzulegen. Die Bewertung erhobener Messparameter im Zusammenhang mit der klinischen Gesamtsituation des Patienten erlaubt die Entwicklung eines weiterführenden Therapiekonzepts und die Festlegung von Zielkriterien zur Kontrolle des Behandlungserfolgs. Bislang existieren Leitlinien und Empfehlungen lediglich für Teilbereiche der kardiochirurgischen Intensivmedizin. So bestehen Leitlinien für den Einsatz des Pulmonalarterienkatheters und der transösophagealen Echokardiographie für diesen speziellen Bereich der postoperativen Patientenversorgung. Die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) und die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) haben sich daher zum Ziel gesetzt, einen nationalen Ansatz zur Sicherung und Verbesserung der Qualität der postoperativen kardiochirurgischen Intensivmedizin mit der vorliegenden evidenzbasierten S3-Konsensusleitlinie zu schaffen. Ziel dieser Leitlinie ist eine Bewertung der verfügbaren Monitoringverfahren im Hinblick auf Indikationen, Vorgehen, Aussagen, Limitationen, Kontraindikationen und Risiken; weiterhin die Differenzialtherapie mit Volumenersatzlösungen vs. positiv inotropen und vasoaktiven Substanzen, die differenzierte Katecholamintherapie einschließlich der Inodilatoren und Kalziumsensitizer sowie die Einsatzkriterien der intraaortalen Ballonpumpe. Die Leitlinie ist in einem standardisierten Prozess nach Vorgaben der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) erstellt worden. Die Verabschiedung der Kernaussagen der Leitlinie erfolgte in zwei Konsensusverfahren unter Moderation der AWMF. Hemodynamic monitoring and adequate volume therapy, as well as treatment with positive inotropic drugs and vasopressors are the basic principles of postoperative intensive care treatment of patients after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations with respect to evidence-based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of target criteria to evaluate the effect of treatment. Up to now there have only been guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, such as the use of pulmonary artery catheters or transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. The goal of these guidelines is to assess the available monitoring methods with respect to indications, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. These guidelines have been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the AWMF. SchlüsselwörterIntensivmedizin-Kardiochirurgie-Monitoring-Volumentherapie-Positiv-inotrope und vasoaktive Substanzen KeywordsIntensive care medicine-Cardiothoracic surgery-Monitoring-Volume therapy-Positive inotropic and vasoactive drugsZeitschrift für Herz- Thorax- und Gefäßchirurgie 10/2010; 24(5):294-310. DOI:10.1007/s00398-010-0790-1