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Communications to the Editor |

Blood and Starch in Cardiac Surgery* FREE TO VIEW

Aryeh Shander, MD, FCCP; Tanuja Rijhwani, MBBS, MPH; David Moskowitz, MD; Richard Spence, MD
Author and Funding Information

Affiliations: Englewood Hospital and Medical Center, Englewood, NJ,  St. Agnes Healthcare, Baltimore, MD

Correspondence to: Tanuja Rijhwani, MBBS, MPH, Director, Clinical Research, Department of Anesthesiology, Englewood Hospital and Medical Center, Englewood, NJ 07631; e-mail: tanuja.rijhwani@ehmc.com



Chest. 2004;125(6):2369-2370. doi:10.1378/chest.125.6.2369
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Published online

To the Editor:

The recent article by Avorn et al (October 2003)1purports to show an association between the use of hydroxyethyl starch (HES) and excessive postoperative bleeding after coronary artery bypass surgery (CABG). This article resurrects the unresolved controversy regarding the use of HES in cardiac surgery and the emerging concern of clinically significant bleeding. Several prospective randomized trials,29 observational studies,911 and meta-analyses,1213 have investigated the suspected association between HES use and bleeding after CABG.

Most randomized studies on HES and bleeding have failed to show any clinically significant bleeding differences. The published retrospective studies showing an increased incidence of blood loss have received the most press but are inherently limited due to study design. Cope et al11 retrospectively reviewed the use of hetastarch infusion based on perioperative exposure to HES and transfusion requirements during the first 24 h postoperatively. The selection bias of this study favored those with hemodynamic compromise or those with greater severity of illness. The meta-analysis by Wilkes et al14 shows that the difference in pooled mean blood loss in the albumin group was 693 ± 350 mL compared with 789 ± 487 mL in the HES group, a difference of 96 mL only.

We believe that the article by Avorn et al1 fails to show an association between HES and postoperative bleeding, as cited in the majority of related studies. The title leads the reader to believe that hetastarch increases the risk of bleeding, but the authors did not report any single measure of bleeding. They did not account for the number of bleeding episodes nor did they use quantifiable measures, ie, chest tube drainage volume. Some of the study design limitations were that no clear definitions of nonsurgical bleeding or proper criteria for correction of microvascular bleeding were used. Measurement of hematocrit from the drainage fluid and collection of blood samples for baseline laboratory parameters indicative of blood loss would have been more reliable estimates of perioperative blood loss. These indicators should be considered as one of the primary outcome variables. Although transfusions may reflect bleeding, previous data,1516 suggest that transfusing blood in cardiac surgery is behavioral rather than a response to blood loss. Re-operation (exploration for bleeding) in coronary bypass surgery cannot be used as a measure of drug-induced coagulopathy unless one completely excludes other causes for bleeding, ie, heparin-protamine activity, large-vessel bleeding, and overall patient coagulation status. Simple changes in preoperative, intraoperative, and postoperative hemoglobin and hematocrit values would help clarify their claims, although even these are confounded by volume changes.

The patients selected in the study by Avorn et al1 were those who had received ≥ 3 U packed RBCs within 72 h after undergoing CABG procedure; all other CABG patients were control subjects. The higher comorbidity in the cases (HES group) may act as a confounder leading to higher transfusion rates as a result of lower transfusion thresholds for more severely ill patients.

The editorial accompanying this study recommends a change in practice without convincing evidence. Lack of sufficient data should not be replaced with personal interpretation of study results. This invariably can be misleading to the medical community.

References

Avorn, J, Patel, M, Levin, R, et al (2003) Hetastarch and bleeding complications after coronary surgery.Chest124,1437-1442. [CrossRef] [PubMed]
 
Kasper, SM, Meinert, P, Kampe, S, et al Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at recommended doses.Anesthesiology2003;99,42-47. [CrossRef] [PubMed]
 
Haisch, G, Boldt, J, Krebs, C, et al Influence of a new hydroxyethylstarch preparation (HES 130/0.4) on coagulation in cardiac surgical patients.J Cardiothorac Vasc Anesth2001;15,316-321. [CrossRef] [PubMed]
 
Gallandat Huet, RC, Siemons, AW, Baus, D, et al A novel hydroxyethyl starch (Voluven) for effective perioperative plasma volume substitution in cardiac surgery.Can J Anaesth2000;47,1207-1215. [CrossRef] [PubMed]
 
Munsch, CM, MacIntyre, E, Machin, SJ, et al Hydroxyethyl starch: an alternative to plasma for postoperative volume expansion after cardiac surgery.Br J Surg1988;75,675-678. [CrossRef] [PubMed]
 
Palanzo, DA, Parr, GV, Bull, AP, et al Hetastarch as a prime for cardiopulmonary bypass.Ann Thorac Surg1982;34,680-683. [CrossRef] [PubMed]
 
Sade, RM, Stroud, MR, Crawford, FA, Jr, et al A prospective randomized study of hydroxyethyl starch, albumin, and lactated Ringer’s solution as priming fluid for cardiopulmonary bypass.J Thorac Cardiovasc Surg1985;89,713-722. [PubMed]
 
Kirklin, JK, Lell, WA, Kouchoukos, NT Hydroxyethyl starch versus albumin for colloid infusion following cardiopulmonary bypass in patients undergoing myocardial revascularization.Ann Thorac Surg1984;37,40-46. [CrossRef] [PubMed]
 
Knutson, JE, Deering, JA, Hall, FW, et al Does intraoperative hetastarch administration increase blood loss and transfusion requirements after cardiac surgery?Anesth Analg2000;90,801-807. [CrossRef] [PubMed]
 
Keyser, EJ, Latter, DA, Morin, JE, et al Pentastarch versus albumin in cardiopulmonary bypass prime: impact on blood loss.J Card Surg1999;14,279-286. [CrossRef] [PubMed]
 
Cope, M, Jeffrey, T, Banks, B, et al Intraoperative hetastarch infusion impairs hemostasis after cardiac operations.Ann Thorac Surg1997;63,78-82. [CrossRef] [PubMed]
 
Strauss, R Review of the effects of hydroxyethyl starch on the blood coagulation system.Transfusion1981;21,299-302. [CrossRef] [PubMed]
 
Wilkes, NJ, Woolf, RL, Powanda, MC, et al Hydroxyethyl starch in balanced electrolyte solution (Hextend): pharmacokinetic and pharmacodynamic profiles in healthy volunteers.Anesth Analg2002;94,538-544. [CrossRef] [PubMed]
 
Wilkes, MM, Navickis, RJ, Sibbald, WJ Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding.Ann Thorac Surg2001;72,527-533. [CrossRef] [PubMed]
 
Goodnough, L, Johnston, M The variability of transfusion practice in coronary artery bypass surgery.JAMA1991;265,86-90. [CrossRef] [PubMed]
 
Stover, E, Siegel, LC, Body, SC, et al Institutional variability in red blood cell conservation practices for coronary artery bypass graft surgery: Institutions of the MultiCenter Study of Perioperative Ischemia Research Group.J Cardiothorac Vasc Anesth2000;14,171-176. [CrossRef] [PubMed]
 

Figures

Tables

References

Avorn, J, Patel, M, Levin, R, et al (2003) Hetastarch and bleeding complications after coronary surgery.Chest124,1437-1442. [CrossRef] [PubMed]
 
Kasper, SM, Meinert, P, Kampe, S, et al Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at recommended doses.Anesthesiology2003;99,42-47. [CrossRef] [PubMed]
 
Haisch, G, Boldt, J, Krebs, C, et al Influence of a new hydroxyethylstarch preparation (HES 130/0.4) on coagulation in cardiac surgical patients.J Cardiothorac Vasc Anesth2001;15,316-321. [CrossRef] [PubMed]
 
Gallandat Huet, RC, Siemons, AW, Baus, D, et al A novel hydroxyethyl starch (Voluven) for effective perioperative plasma volume substitution in cardiac surgery.Can J Anaesth2000;47,1207-1215. [CrossRef] [PubMed]
 
Munsch, CM, MacIntyre, E, Machin, SJ, et al Hydroxyethyl starch: an alternative to plasma for postoperative volume expansion after cardiac surgery.Br J Surg1988;75,675-678. [CrossRef] [PubMed]
 
Palanzo, DA, Parr, GV, Bull, AP, et al Hetastarch as a prime for cardiopulmonary bypass.Ann Thorac Surg1982;34,680-683. [CrossRef] [PubMed]
 
Sade, RM, Stroud, MR, Crawford, FA, Jr, et al A prospective randomized study of hydroxyethyl starch, albumin, and lactated Ringer’s solution as priming fluid for cardiopulmonary bypass.J Thorac Cardiovasc Surg1985;89,713-722. [PubMed]
 
Kirklin, JK, Lell, WA, Kouchoukos, NT Hydroxyethyl starch versus albumin for colloid infusion following cardiopulmonary bypass in patients undergoing myocardial revascularization.Ann Thorac Surg1984;37,40-46. [CrossRef] [PubMed]
 
Knutson, JE, Deering, JA, Hall, FW, et al Does intraoperative hetastarch administration increase blood loss and transfusion requirements after cardiac surgery?Anesth Analg2000;90,801-807. [CrossRef] [PubMed]
 
Keyser, EJ, Latter, DA, Morin, JE, et al Pentastarch versus albumin in cardiopulmonary bypass prime: impact on blood loss.J Card Surg1999;14,279-286. [CrossRef] [PubMed]
 
Cope, M, Jeffrey, T, Banks, B, et al Intraoperative hetastarch infusion impairs hemostasis after cardiac operations.Ann Thorac Surg1997;63,78-82. [CrossRef] [PubMed]
 
Strauss, R Review of the effects of hydroxyethyl starch on the blood coagulation system.Transfusion1981;21,299-302. [CrossRef] [PubMed]
 
Wilkes, NJ, Woolf, RL, Powanda, MC, et al Hydroxyethyl starch in balanced electrolyte solution (Hextend): pharmacokinetic and pharmacodynamic profiles in healthy volunteers.Anesth Analg2002;94,538-544. [CrossRef] [PubMed]
 
Wilkes, MM, Navickis, RJ, Sibbald, WJ Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding.Ann Thorac Surg2001;72,527-533. [CrossRef] [PubMed]
 
Goodnough, L, Johnston, M The variability of transfusion practice in coronary artery bypass surgery.JAMA1991;265,86-90. [CrossRef] [PubMed]
 
Stover, E, Siegel, LC, Body, SC, et al Institutional variability in red blood cell conservation practices for coronary artery bypass graft surgery: Institutions of the MultiCenter Study of Perioperative Ischemia Research Group.J Cardiothorac Vasc Anesth2000;14,171-176. [CrossRef] [PubMed]
 
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