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      Effect of 6% Hydroxyethyl Starch 130/0.4 as a Priming Solution on Coagulation and Inflammation Following Complex Heart Surgery


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          Prolonged duration of cardiopulmonary bypass aggravates the degree of inflammation and coagulopathy. We investigated the influence of 6% hydroxyethyl starch (HES) 130/0.4 on coagulation and inflammation compared with albumin when used for both cardiopulmonary bypass priming and perioperative fluid therapy in patients undergoing complex valvular heart surgery.

          Materials and Methods

          Fifty four patients were randomly allocated into albumin-HES, albumin-nonHES, and HES-HES groups. The cardiopulmonary bypass circuit was primed with 5% albumin in the albumin-HES and albumin-nonHES group, and with HES in the HES-HES group. As perioperative fluid, only plasmalyte was used in the albumin-nonHES group whereas HES was used up to 20 mL/kg in the albumin-HES and albumin-HES group. Serial assessments of coagulation profiles using the rotational thromboelastometry and inflammatory markers (tissue necrosis factor-α, interleukin-6, and interleukin-8) were performed.


          Patients' characteristics and the duration of cardiopulmonary bypass (albumin-HES; 137±34 min, HES-HES; 136±47 min, albumin-nonHES; 132±39 min) were all similar among the groups. Postoperative coagulation profiles demonstrated sporadic increases in clot formation time and coagulation time, without any differences in the actual amount of perioperative bleeding and transfusion requirements among the groups. Also, inflammatory markers showed significant activation after cardiopulmonary bypass without any differences among the groups.


          Even in the presence of prolonged duration of cardiopulmonary bypass, HES seemed to yield similar influence on the ensuing coagulopathy and inflammatory response when used for priming and perioperative fluid therapy following complex valvular heart surgery compared with conventional fluid regimen including albumin and plasmalyte.

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          Most cited references30

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          Hydroxyethyl starches: different products--different effects.

          With the development of a new generation of hydroxyethyl starches (HES), there has been renewed interest in their clinical potential. High doses of first- and second-generation HES were associated with adverse effects on renal function, coagulation, and tissue storage, thereby limiting their clinical applicability. Newer HES products have lower molar substitution and in vivo molecular weight, resulting in more rapid metabolism and clearance. In this review article, the differences between HES generations are highlighted, with particular emphasis on the improved safety profile of the third generation products. These improvements have been achieved with no loss of efficacy, and they contradict the assumption that efficacy of HES solutions is directly linked to plasma concentration. The impact of source material on structure and pharmacokinetics is highlighted, and the role of the carrier solution is critically assessed.
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            Classification and staging of acute kidney injury: beyond the RIFLE and AKIN criteria.

            Acute kidney injury (AKI) is often overlooked in hospitalized patients, despite the fact that even mild forms are strongly associated with poor clinical outcomes such as increased mortality, morbidity, cardiovascular failure and infections. Research endorsed by the Acute Dialysis Quality Initiative led to the publication of a consensus definition for AKI--the RIFLE criteria (Risk, Injury, Failure, Loss of function, and End-stage renal disease)--which was designed to standardize and classify renal dysfunction. These criteria, along with revised versions developed by the AKI Network (AKIN), can detect AKI with high sensitivity and high specificity and describe different severity levels that aim to predict the prognosis of affected patients. The RIFLE and AKIN criteria are easy to use in a variety of clinical and research settings, but have several limitations: both utilize an increase in serum creatinine level from a hypothetical baseline value and a decrease in urine output, but these surrogate markers of renal impairment manifest relatively late after injury has occurred and do not consider the nature or site of the kidney injury. New biomarkers for AKI have shown promise for early diagnosis and prediction of the prognosis of AKI. As more data become available, they could, in the future, be incorporated into improved definitions or criteria for AKI.
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              Coagulation disorders of cardiopulmonary bypass: a review.

              Postoperative bleeding is one of the most common complications of cardiac surgery. Extensive surgical trauma, prolonged blood contact with the artificial surface of the cardiopulmonary bypass (CPB) circuit, high doses of heparin, and hypothermia are all possible triggers of a coagulopathy leading to excessive bleeding. Platelet activation and dysfunction also occur and are caused mainly by heparin, hypothermia, and inadequate protamine administration. Heparin and protamine administration based on heparin concentrations as opposed to fixed doses may reduce coagulopathy and postoperative blood loss. A better comprehension of the multifactorial mechanisms of activation of coagulation, inflammation, and fibrinolytic pathways during CPB may enable a more effective use of the technical and pharmaceutical options which are currently available.

                Author and article information

                Yonsei Med J
                Yonsei Med. J
                Yonsei Medical Journal
                Yonsei University College of Medicine
                01 May 2014
                01 April 2014
                : 55
                : 3
                : 625-634
                [1 ]Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University, Seoul, Korea.
                [2 ]Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea.
                Author notes
                Corresponding author: Dr. Young-Lan Kwak, Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Severance Biomedical Science Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea. Tel: 82-2-2228-8513, Fax: 82-2-364-2951, ylkwak@ 123456yuhs.ac
                © Copyright: Yonsei University College of Medicine 2014

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Funded by: Korea University Grant
                Award ID: K1220971
                Original Article
                Cardiac & Cardiovascular Systems

                blood coagulation,inflammation,cardiopulmonary bypass,cardiac surgical procedures
                blood coagulation, inflammation, cardiopulmonary bypass, cardiac surgical procedures


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