Abstract
BackgroundThe European Medicines Agency does not recommend the use of hydroxyethyl starch-based volume replacement solutions in critically ill patients due to an increased risk of renal failure. However, this recommendation is questionable for its perioperative use. Several recent randomised controlled studies do not indicate a risk for renal failure—not even after high-risk surgery. Human albumin is used in our neurointensive care unit as a part of the “Lund concept” of brain injury resuscitation, and albumin has been introduced in elective neurosurgery instead of starch. The aim of our prospective unblinded observational cohort study was to compare the degree of dilutive coagulopathy after albumin and starch intra-operative fluid therapy.MethodsThirty-nine patients undergoing elective brain tumour surgery with craniotomy received either 130/0.42 hydroxyethyl starch or 5 % albumin infusions. The first 18 patients received starch, whereas the rest received albumin. Rotational thromboelastometry with ROTEM and platelet aggregometry with Multiplate were performed before surgery, after the first and second consecutive colloid infusions (250/500 ml albumin or 500/1000 ml starch) and at the end of surgery.ResultsBoth intra- and inter-group comparisons showed more deranged ROTEM parameters after the higher doses of starch. Multiplate detected changes only in the albumin group after 500-ml infusion. Blood los did not differ between groups, nor did haemoglobin preoperatively or at end of surgery. Lower volumes of albumin were required to maintain stable intra-operative haemodynamic parameters; 250/500 ml albumin corresponded to 500/1000 ml starch.ConclusionsHydroxyethyl starch affected coagulation at lower volumes, with a more prominent effect on clot structure at the end of surgery, corroborating previous research. Only albumin decreased platelet aggregation, and 5 % albumin had a more potential volume effect than 130/0.42 hydroxyethyl starch.
Highlights
The European Medicines Agency does not recommend the use of hydroxyethyl starch-based volume replacement solutions in critically ill patients due to an increased risk of renal failure
At the end of surgery, changes were detected in all rotational thromboelastometry (ROTEM) parameters except for clotting time (CT)
Our results indicate that the two types of colloid infusions induce coagulation defects in elective brain tumour neurosurgical patients, most notably seen with ROTEM parameters and after hydroxyethyl starch (HES) infusion
Summary
The European Medicines Agency does not recommend the use of hydroxyethyl starch-based volume replacement solutions in critically ill patients due to an increased risk of renal failure. This recommendation is questionable for its perioperative use. HES infusions decrease plasma levels of fibrinogen and several coagulation factors, leading to weaker and smaller clots (Fenger-Eriksen et al 2009). It can decrease circulating levels of von Willebrand’s factor (F), impairing platelet function (de Jonge et al 2001)
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