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Hetastarch in Perioperative Volume Expansion FREE TO VIEW

John C. Alexander, Jr
Author and Funding Information

Affiliations: Hackensack, NJ
 ,  Dr. Alexander is Chief of Cardiothoracic Surgery, Hackensack University Medical Center.

Correspondence to: John C. Alexander, Jr, MD, FCCP, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601; e-mail: jalexander@humed.com

Chest. 2003;124(4):1194-1196. doi:10.1378/chest.124.4.1194
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This issue of CHEST contains an article written by Avorn and associates (see page 1437) entitled, “Hetastarch and Bleeding Complications After Coronary Artery Surgery.” Bleeding is a major concern for surgeons in the perioperative period. Reoperation for bleeding, the associated increase in morbidity related to exposure of the patient to blood and blood products, and the expense associated with bleeding are significant. Postoperative bleeding is, in my experience, most frequently related to platelet dysfunction as the root cause. When I take patients back into the operating room for bleeding, I can almost always find one or more specific “bleeders,” but I am convinced that most of these sites of bleeding would have stopped if the patient’s coagulation mechanisms were intact. There have been many studies and strategies developed to prevent perioperative bleeding, including the use of aprotinin to reduce damage to platelets during the procedure, the preprocedural deposit of blood and platelets, the perioperative sequestration of blood and platelets, as well as the great care taken in the operating room, which is best described as the “art” of surgery. Despite all best efforts, bleeding occurs in association with cardiac surgery for a variety of reasons. The procedure is a major surgical insult. Large doses of heparin, which are imprecisely reversed with protamine after the procedure, are administered in order to prevent clotting in the pump. The heart-lung machine damages blood elements, in particular platelets. The postoperative platelet count, while it may be considered “adequate” in numbers, frequently is simply counting the presence of platelets shells that either do not work at all or do not work very well.

Surgeons also are facing patients who have been treated with very powerful platelet inhibitors prior to surgery. In addition, platelet inhibition is a cornerstone of the treatment of unstable angina and the management of patients who have undergone angioplasty or stent placement. Surgeons also are being asked to operate on “older and sicker” patients.

In summary, bleeding is a major problem for cardiac surgeons. The causes of bleeding are many, and there are a variety of contributing factors that are unavoidable. Surgeons, by necessity, have had to learn to deal with this patient population and to understand and develop strategies to manage perioperative bleeding.

The article by Avorn et al addresses the contribution of hetastarch as a volume expander to perioperative bleeding, as measured in the postoperative period. Hetastarch is an excellent volume expander. There has been much controversy in the literature about whether or not hetastarch actually contributes to the anticoagulant state of the patient. The suggestions have been made that hetastarch dilutes clotting factors in the blood, but what is more likely is that if it is active, it inhibits platelets. The authors studied the amount of hetastarch administered in the operating room and then measured postoperative outcomes in terms of the amount of blood products the patient received or the necessity for the patient to return to the operating room due to bleeding. The authors have chosen relatively gross outcome variables, but there is little doubt from the data that they present that there is an association between postoperative bleeding and the use of hetastarch in the operating room. The propensity for bleeding is also dose-dependent. The statistics in the authors’ study indicate that there is a strong and undeniable association between hetastarch use in the operating room and perioperative bleeding.

The authors point out very clearly that their study was not blinded. They also make it clear that the institutional bias is not to give hetastarch because of the presumption that hetastarch is associated with bleeding. If anything, the study is biased to demonstrate that hetastarch is not related to bleeding.

The authors do not offer any additional information about the mechanism through which hetastarch contributes to bleeding. They have adequately reviewed the literature and have added, in my opinion, an important study to the literature, which helps us understand the practical importance of hetastarch in the perioperative period. The authors suggest at the conclusion of their article that a double-blinded study should be performed to substantiate their findings further. However, I doubt seriously whether this will ever be done.

From a practical standpoint, surgeons are faced with the need for volume expansion in the postoperative period for a variety of reasons. Blood loss invariably occurs in major cardiac surgery, and the patients are frequently significantly vasodilated and have a capillary leak with significant third spacing during the early postoperative hours. I have been a strong proponent of the use of hetastarch as a volume expander in the postoperative period because of the theoretical value of the oncotic nature of the fluid. Other options for volume expansion in the perioperative period include the administration of normal saline solution and albumin. The unfortunate problem with normal saline solution is that only a small portion of it remains intravascular, at least in the early period following surgery. Patients, if given only normal saline solution, have significant weight gain and fluid retention because of the third-space phenomenon. The other option is an albumen-based volume expander. At present, I use a combination of albumen and normal saline solution, and make every effort not to use hetastarch. This study has convinced me that there is valid, although not well understood, scientific proof at a mechanistic level that supports the statement that hetastarch in the perioperative period is associated with persistent bleeding.

The authors are to be congratulated for a well-done study and, in particular, for their recognition and understanding of their own internal bias, which they outline very well in the article. I believe that this article has made a significant contribution to the literature. This article has certainly changed my strategy of volume expansion in cardiac surgery patients.




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