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      The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis

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      Author(s): , , ,
      Publication date (Electronic):
      Journal: Critical Care
      Publisher: BioMed Central

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          Abstract

          Introduction

          Recent studies in septic patients showed that adverse effects of hydroxyethyl starches (HESs) possibly outweigh their benefits in severely impaired physiological haemostasis. It remains unclear whether this also applies to patient populations that are less vulnerable. In this meta-analysis, we evaluated the impact of various HES generations on safety and efficacy endpoints in patients undergoing cardiac surgery.

          Methods

          We searched the PubMed, Embase and Cochrane Central Register of Controlled Trials databases for randomised controlled trials (RCTs) in the English or German language comparing the use of HES to any other colloid or crystalloid during open heart surgery.

          Results

          Blood loss and transfusion requirements were higher for older starches with mean molecular weights more than 200 kDa compared to other volume substitutes. In contrast, this effect was not observed with latest-generation tetrastarches (130/0.4), which performed even better when compared to albumin (blood loss of tetrastarch versus albumin: standardised mean difference (SMD), −0.34; 95% CI, −0.63, −0.05; P = 0.02; versus gelatin: SMD, −0.06; 95% CI, −0.20, 0.08; P = 0.39; versus crystalloids: SMD, −0.05; 95% CI, −0.20, 0.10; P = 0.54). Similar results were found for transfusion needs. Lengths of stay in the intensive care unit or hospital were significantly shorter with tetrastarches compared to gelatin (intensive care unit: SMD, −0.10; 95% CI, −0.15, −0.05; P = 0.0002) and crystalloids (hospital: SMD, −0.52; 95% CI, −0.90, −0.14; P = 0.007).

          Conclusions

          In this meta-analysis of RCTs, we could not identify safety issues with tetrastarches compared with other colloid or crystalloid solutions in terms of blood loss, transfusion requirements or hospital length of stay in patients undergoing cardiac surgery. The safety data on coagulation with older starches raise some issues that need to be addressed in future trials.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13054-014-0656-0) contains supplementary material, which is available to authorized users.

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          Most cited references70

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          Hydroxyethyl starches: different products--different effects.

          Martin Westphal, Michael F M James, Sibylle Kozek-Langenecker … (2009)
          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.
          Article 0 comments Cited 76 times – based on 0 reviews     Review now
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            The impact of the glycocalyx on microcirculatory oxygen distribution in critical illness.

            Matthias Jacob, Martin Westphal, Daniel Chappell (2009)
            Main problems of critical illness and sepsis are an altered oxygen distribution and microvascular dysfunction linked to tissue oedema. This review seeks to analyse the role of the endothelial glycocalyx in this context. The presence of vascular leakage is typically associated with interstitial oedema, arterial hypotension, hypovolaemia and often a bad outcome in patients with systemic inflammation. Early goal-directed therapy provides significant benefits in severe sepsis and septic shock, but is mostly aimed at improving macrohaemodynamics. Recent data suggest that microcirculation also contributes significantly to the pathophysiology of critical illness. In fact, the endothelial glycocalyx plays a major role in vascular barrier competence. According to experimental evidence, it can easily be degraded in the presence of inflammation, but, theoretically also protected by several measures. Clinical studies revealed a positive correlation of the severity of sepsis and ischaemia with mortality, but also with a deterioration of the endothelial glycocalyx. Future investigation should focus on the preservation of this structure and assess microcirculatory variables to judge the success of cardiocirculatory therapy. Deterioration of the endothelial glycocalyx initiates a breakdown of the vascular barrier in systemic inflammatory response syndrome and sepsis. Preserving this structure in critical illness might be a future therapeutical goal to improve microcirculatory oxygen distribution.
            Article 0 comments Cited 55 times – based on 0 reviews     Review now
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              Effect of volume loading with 1 liter intravenous infusions of 0.9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: a randomized, three-way crossover study in healthy volunteers.

              Mark M Aloysius, Krista Ingram, P. Allison … (2010)
              To study the changes in blood volume and hormones controlling sodium and water homeostasis after infusions of 0.9% saline, Gelofusine (4% succinylated gelatin in 0.7% saline, weight-average molecular weight 30 kD), and Voluven (6% hydroxyethyl starch in 0.9% saline, weight-average molecular weight 130 kD) in healthy volunteers. Randomized, three-way crossover study. University teaching hospital. Ten healthy adult male volunteers. Volunteers received 1-L infusions of 0.9% saline, Gelofusine, and Voluven over 1 hr on three occasions. Body weight, hematocrit, serum biochemistry, and plasma concentrations of vasopressin, aldosterone, brain natriuretic peptide, and total renin were measured before infusion and hourly thereafter for 6 hrs. Changes in body water, blood volume, and extravascular fluid volume were calculated. Although changes in body weight (total body water) after the infusions were similar, blood volume expansion by the two colloids was significantly greater than that produced by 0.9% saline (p < .01). At the end of infusions, 68%, 21%, and 16% of the infused volumes of 0.9% saline, Gelofusine, and Voluven, respectively, had escaped from the intravascular space to the extravascular space. Over the 6 hrs, the magnitude and duration of blood volume expansion by the two colloids were similar (p = .70). There were no significant differences in urinary volume, osmolality, and sodium content after the three infusions. Hormonal changes were similar after the three infusions, with the increase in natriuretic peptide being transient. The reduction in aldosterone and total renin concentrations was more sustained. The effects of Gelofusine and Voluven were similar despite the 100 kD difference in weight-average molecular weight. Excretion of an acute fluid load containing sodium and chloride may be dependent on a sustained suppression of the renin-angiotensin-aldosterone system rather than on natriuretic peptides.
              Article 0 comments Cited 53 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Matthias Jacob: matthias.jacob@med.uni-muenchen.de
                Jean-Luc Fellahi: jean-luc.fellahi@chu-lyon.fr
                Daniel Chappell: daniel.chappell@med.uni-muenchen.de
                Andrea Kurz: ak@or.org
                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Electronic): 4 December 2014
                Publication date PMC-release: 4 December 2014
                Publication date (Print): 2014
                Volume: 18
                Issue: 6
                Electronic Location Identifier: 656
                Affiliations
                [ ]Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Therapy, Harlaching Hospital, Munich Municipal Hospital Group, Munich, Germany
                [ ]Department of Anesthesiology and Critical Care, Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Hospices Civils de Lyon, 28 avenue du Doyen Lépine, Lyon, Bron Cedex 69677 France
                [ ]Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, 69008 France
                [ ]Department of Anesthesiology, University Hospital of Munich, Nussbaumstrasse 20, Munich, 80336 Germany
                [ ]Department of General Anesthesiology, Cleveland Clinic Main Campus, Mail Code E31, 9500 Euclid Avenue, Cleveland, OH 44195 USA
                Article
                Publisher ID: 656
                DOI: 10.1186/s13054-014-0656-0
                PMC ID: 4301454
                PubMed ID: 25475406
                SO-VID: a9a10f5c-45a3-444d-87ac-b638d04f880c
                Copyright © © Jacob et al.; licensee BioMed Central. 2014
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 8 September 2014
                Date accepted : 11 November 2014
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2014

                ScienceOpen disciplines: Emergency medicine & Trauma
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                ScienceOpen disciplines: Emergency medicine & Trauma

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