Hydroxyethyl Starch Group Research Articles

Hypertonic/Hyperoncotic Fluid Resuscitation After Hemorrhagic Shock in Dogs

We compared canine systemic and cerebral hemodynamics after resuscitation from hemorrhagic shock with 4 mL/kg (a volume approximating 12% of shed blood volume) of 7.2% saline (HS; 1233 mEq/L sodium), 20% hydroxyethyl starch (HES) in 0.8% saline, or a combination fluid consisting of 20% hydroxyethyl starch in 7.2% saline (HS/HES). Eighteen endotracheally intubated mongrel dogs (18-24 kg) were ventilated to maintain normocarbia with 0.5% halothane in nitrous oxide and oxygen (60:40). After a 30-min period of hemorrhagic shock (mean arterial blood pressure = 40 mm Hg), extending from time T0 to T30, animals received one of three randomly assigned intravenous resuscitation fluids: HS, HES, or HS/HES. Data were collected at baseline, at the beginning and end of the shock period (T0 and T30), immediately after fluid infusion (T35), and at 60-min intervals for 2 h (T95, T155). After resuscitation, mean arterial blood pressure and cardiac output increased similarly in all groups, but failed to return to baseline. Intracranial pressure decreased during shock and increased slightly, immediately after resuscitation in all groups. During shock, cerebral blood flow (cerebral venous outflow method) declined in all groups. After resuscitation, cerebral blood flow increased, exceeding baseline in the HS and HS/HES groups but remaining low in the HES group (P less than 0.05 HS vs HES at T35). We conclude that small-volume resuscitation (4 mL/kg) with HS, HS/HES, or HES does not effectively restore or sustain systemic hemodynamics in hemorrhaged dogs. In dogs without intracranial pathology, the effects on cerebral hemodynamics are also comparable, except for transiently greater cerebral blood flow in the HS group in comparison with the HES group.

Hydroxyethyl Starch (HES) as a Priming Solution in Cardiopulmonary Bypass

Various priming solutions are currently used to prime heart-lung machines for cardiac operations. Hemodilution has resulted in considerable conservation of blood, as well as diminution of plasma and corpuscle damage, by decreasing the concentration of these elements in blood during extracorporeal circulation. Controversy has existed regarding the relative efficacy of various hemodilution solutions. In this prospective study two groups of similar open-heart patients, the first receiving hydroxyethyl starch (HES) and the second 5% albumin as a priming solution were compared. Hematocrit, platelet counts, plasma fibrinogen levels, postoperative drainage, prothrombin and partial thromboplastin time, urine output, and administration of blood products were investigated and compared. There were no differences in chest tube drainage, blood use, urine output, coagulation, and hematologic and hemodynamic parameters, except for an early postoperative increase in platelet count in the HES group. HES is a safe, effective, inexpensive volume expander in cardiac surgery patients.

RETRACTED: Cardiorespiratory responses to hypertonic saline solution in cardiac operations

Infusion of small volumes of hypertonic saline solution (HS) seems to be of benefit in patients with impaired perfusion. The cardiorespiratory response to a 7.2% NaCl solution prepared in hydroxyethylstarch (HES) solution was investigated prospectively in patients undergoing prolonged cardiopulmonary bypass (CPB) (HS-HES group; n = 15); 6% HES 200/0.5 solution was infused in a control group (HES group; n = 15). Volume was given preoperatively to double low pulmonary artery occlusion pressure (less than 4 mm Hg) within 20 minutes. Hemodynamics, oxygen transport variables, and pulmonary gas exchange were studied before and after infusion as well as before and after CPB. Significantly less HS-HES solution (3.06 +/- 0.2 mL/kg) than 6% HES 200/0.5 solution (10.3 +/- 0.9 mL/kg) was necessary to double baseline pulmonary artery occlusion pressure. Fluid balance during CPB was negative in the HS-HES patients (-0.05 mL/kg.min CPB) and was lowest in this group even 5 hours after CPB. Mean arterial pressure, pulmonary arterial pressure, and heart rate were without differences between the groups. Changes in cardiac index (+40%) and total systemic resistance (-25%) were significantly most pronounced in the HS-HES patients, continuing even until the end of operation. Pulmonary gas exchange (arterial oxygen tension, intrapulmonary right-to-left shunting) was least compromised in these patients, particularly after bypass. Oxygen consumption was without difference between the groups; oxygen delivery increased significantly more in the HS-HES patients due to the larger increase in cardiac output.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrovascular Effects of Small Volume Resuscitation from Hemorrhagic Shock

To determine if hypertonic and hyperoncotic resuscitation solutions exerted comparable effects on cerebral hemodynamics following hemorrhagic shock, we compared randomly assigned, equal volumes (6.0 ml/kg) of hypertonic (7.2%) saline (HS) and hyperoncotic (20%) hydroxyethyl starch (HES) for resuscitation from acute experimental hemorrhage in 12 anesthetized dogs. Regional cerebral blood flow (radiolabeled microspheres), intracranial pressure (cisternal catheter), and systemic hemodynamics were recorded. Rapid hemorrhage reduced the mean arterial pressure to 45 mm Hg for 30 min. Resuscitation fluids were infused over 5 min. Both fluids restored mean arterial pressure and cardiac output equally. However, at 60 min following resuscitation, cardiac output decreased in the HS group in comparison to the HES group (1.7 +/- 0.1 vs. 3.1 +/- 0.2 L/min, p <0.05). Cardiac output rapidly declined, however, in the HS group in comparison to the HES group (p <0.05 60 min following resuscitation). Intracranial pressure and cerebral perfusion pressure were similar at all intervals. Regional cerebral blood flow was similar following both fluids. Neither fluid restored cerebral oxygen transport to baseline values. Based on these data, the authors conclude that, following severe hemorrhagic shock of brief duration, systemic and cerebral hemodynamic values are restored equally well by highly concentrated colloid or by hypertonic saline, although hypertonic saline only transiently improves cardiac output.

Acute preoperative hemodilution in cardiac surgery: Volume replacement with a hypertonic saline-hydroxyethyl starch solution

Preoperative hemodilution (HD) is a recommended practice in cardiac surgery that conserves blood and reduces the complications of homologous blood transfusion. In 45 patients undergoing myocardial revascularization, HD was performed preoperatively. Withdrawn volume (10 mL/kg) was replaced either by a new hypertonic saline (HS) solution prepared in hydroxyethyl starch (HES) (2,400 mOsm/L, HS-HES group, n = 15) or by a standard low molecular weight hydroxyethyl starch solution (6% HES 200/0.5, HES group, n = 15) to maintain baseline PCWP (acute normovolemic hemodilution [ANH]). Fifteen comparable patients without HD served as controls. Significantly less HS-HES (210 ± 20 mL) than HES 6% (890 ± 90 mL) was necessary to sustain hemodynamics during HD. Stable cardiocirculatory conditions were obtained even after termination of bypass. Fluid balance during cardiopulmonary bypass as well as in the postoperative period was significantly lower in HS-HES-treated patients. With regard to hemodynamics, CI increased most in the HS-HES group (+36%), whereas systemic vascular resistance was lower in these patients. Right ventricular ejection fraction increased only in HS-HES patients (+15%). However, sodium concentration as well as osmolarity increased after volume replacement with HS-HES, without exceeding normal values. None of the patients suffered from organ failure. Pulmonary gas exchange (Pa0 2) was less compromised in the HS-HES patients. There were no renal function differences between the groups. In conclusion, HS solution prepared in HES is an attractive alternative for blood substitution in cardiac patients undergoing acute hemodilution for blood conservation.

Hypertonic Saline Solution-Hetastarch for Fluid Resuscitation in Experimental Septic Shock

Hypertonic colloid solutions have been found efficacious in the resuscitation from hemorrhagic/traumatic shock. The present study investigated the hemodynamic, gasometric, and metabolic effects of hypertonic colloids in endotoxic shock in the dog. Thirty minutes after administration of 3 mg/kg normal body weight of Escherichia coli endotoxin, dogs were randomly assigned to receive 10 mL/kg hydroxyethylstarch (HES) either in 0.9% NaCl (HES, 10 dogs) or in 7.5% NaCl (HT-HES, 10 dogs) in 30 min. Thereafter, 0.9% NaCl solution was administered in volumes adequate to maintain pulmonary artery balloon-occluded pressure at baseline levels. Total fluid administered averaged 64 +/- 30 mL/kg (mean +/- SD) in the HES group and 73 +/- 34 mL/kg in the HT-HES group. As these differences were not statistically significant, total sodium load was higher in the HT-HES group. The persistent volume effect was associated with persistently lower hematocrit and protein levels in the HT-HES group. Initial fluid resuscitation with HT-HES resulted in arterial pressure, cardiac filling pressures, cardiac output, stroke volume, and rates of oxygen delivery and oxygen consumption that were greater than those with HES. Vascular resistances were similar. Analysis of left ventricular function curves also indicated an improvement in cardiac performance. However, these effects almost completely vanished during the remainder of the study. In the HT-HES group, serum sodium and osmolality levels increased to 167 +/- 4 mEq/L and 344 +/- 4 mOsm/kg H2O, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Hydroxyethyl Starch

Hydroxyethyl starch (HES) is a recently developed synthetic volume expander. Forty patients undergoing coronary artery surgery were randomized to receive either HES or plasma protein fraction (PPF) as non-blood volume replacement according to standard haemodynamic criteria. The two groups were comparable in all respects. The median colloid use in the first 24 h was 950 ml (range 500-1500) in the HES group and 975 ml (350-2000) in the PPF group (not significant). There was no difference in blood use, urine output or blood loss between the two groups. Tests of coagulation showed the postoperative changes usual in cardiac surgical patients. There was no difference between the two groups in thrombin time, prothrombin time, activated partial thromboplastin time, or fibrinogen concentration. Similarly, tests of platelet function and Factor VIII and von Willebrand Factor activity showed no difference between the two groups. We conclude that HES is a safe and effective volume expander, and its relative lack of expense and ease of availability make its routine use after cardiac surgery an attractive proposition.

COMBINED COLD STORAGE-PERFUSION PRESERVATION WITH A NEW SYNTHETIC PERFUSATE

Based upon encouraging experimental results, we began employing a synthetic perfusate for cadaver kidney preservation. The new perfusate contains hydroxyethyl starch (HES) as the sole colloid for oncotic support; 107 cadaver kidneys were preserved and transplanted (93 primary, 14 nonprimary) using the HES solution and were compared with our previous experience of 180 cadaver kidneys (161 primary, 19 nonprimary) preserved and transplanted utilizing an albumin-based perfusate. All cadaver kidneys were locally harvested and preserved by machine perfusion. Donor and preservation characteristics in the HES (n = 61) and the albumin (n = 101) groups were comparable, with a mean preservation time of 30.9 hr. Cold storage in combination with hypothermic pulsatile perfusion (HPP) preservation was performed more often in the HES group (68.2% vs. 31.1%, P less than 0.001). Recipient characteristics were also comparable, and all received quadruple immunosuppressive therapy with sequential/Minnesota antilymphoblast globulin/(MALG)/cyclosporine. After primary transplantation, the incidence of immediate function (82.6% vs. 89.2%), preservation-related dialysis (14.9% vs. 8.6%), and primary nonfunction (2.5% vs. 0) were similar between the 2 groups, with trends favoring the latter HES data. One-month serum creatinine (1.8 vs. 1.7 mg/dl) and graft survival (95% vs. 97.8%) also were comparable. Similar trends were present in the retransplant group, including a significantly lower 1-month serum creatinine in the HES group (2.2 vs. 1.5 mg/dl; P less than 0.05). The preservation-related dialysis rate did not differ between primary and nonprimary transplants. Primary nonfunction has not occurred with our new perfusate. Combined cold-storage-HPP preservation with HES perfusate offers advantages over standard retrieval technology and provides excellent immediate allograft function.

Beutelplasmapherese bei Patienten mit peripherer arterieller Verschlußkrankheit im Stadium IIb

The clinical effect of bag-plasmapheresis was investigated in 60 patients with peripheral arterial occlusive disease stage II according to Fontaine. The initial number of patients was subdivided in three groups of 20 individuals using a randomised double-blind placebo-controlled design. Each patient gave 300 ml of blood twice a week for a 6 week duration. Blood plasma was separated in two groups and replaced with Hydroxyethyl-starch (200/0.5 10%) in group 1 and with Laevulose 5% in group 2. Patients in group 3 received their whole blood without any processing. All patients had to undergo a physical training of 45 minutes three times a week. The group who received Hydroxyethylstarch presented a 20% increase in walking distance whereas the increase in the Laevulose group was 5% and approximately 1% in the group receiving whole blood. The increase in walking distance in the Hydroxyethylstarch-group was significant on the 0.1%-level and significantly better than the improvement in walking distance of the other groups. Additionally in this group plasma viscosity showed a 3% decrease, erythrocyte aggregation was reduced by 10%. Results in the Laevulose group were only half as good as in the Hydroxyethylstarch group while parameters remained unchanged in the whole-blood-group. Bag plasmapheresis with Hydroxyethylstarch as substitute leads to an improvement in the walking capacity and blood fluidity thus offering a promising therapy for peripheral vascular occlusive disease.

The haemostatic effects of hydroxyethyl starch (HES) used as a volume expander

Hydroxyethyl starch (HES 450.000/0.7; Hespan 6.0 g/100 ml) was compared with standard crystalloid solutions in postoperative volume replacement in 20 patients undergoing routine orthopaedic surgery. The HES group showed no clinical evidence of haemorrhage and no laboratory evidence of significant haemostatic defects as assessed by standard coagulation tests, platelet aggregation and fibrinogen concentrations. There was a slight shortening in the thrombin time and a smaller increase in post-operative FVIII RAg and FVIII RCof levels in the HES group. HES is a safe and effective volume expander for postoperative use.

A prospective randomized study of hydroxyethyl starch, albumin, and lactated Ringer’s solution as priming fluid for cardiopulmonary bypass

The ideal priming fluid for cardiopulmonary bypass is not known. We designed a study to determine whether there are important differences in the clinical effects of hydroxyethyl starch versus albumin when used in priming fluid, and in the clinical effects of colloid versus crystalloid priming fluid. We prospectively randomized 83 adult patients undergoing coronary artery bypass or valve replacement. All patients were managed by standardized protocol, and they received one of three priming fluids for bypass: hydroxyethyl starch (HES), 26 patients; albumin (ALB), 28 patients, and lactated Ringer's solution (LRS), 29 patients. The groups were stratified by body weight and type of operation. We measured 41 variables relating to operative time factors, fluid balance, bleeding, and organ function (renal, cardiac, and pulmonary) at several time intervals. The LRS group had a significantly lower colloid osmotic pressure than the other two groups, and the HES group had a substantially higher blood viscosity. Although the prothrombin time was significantly lower in the LRS group (p less than 0.05), the differences were very small and not clinically important. The platelet count in the HES group was significantly lower than in the other two groups immediately after bypass, but it was not different by the time the patients left the operating room. There were no differences among the groups in chest tube drainage, blood bank usage, or fluid balance. Postoperatively, the pulmonary shunt fraction was significantly greater in the LRS group. Body weight increased more in the LRS than in the HES and ALB groups (p = 0.01). No adverse reaction to the prime solutions was noted. The differences between the HES and ALB groups--prothrombin time, platelet count, and blood viscosity--had no apparent clinical effects; thus, the two may be considered clinically equivalent. The greater somatic and pulmonary fluid accumulation in the LRS group suggests that colloid is preferable to crystalloid in priming fluid.

Avoidance of Blood Transfusion in Coronary Artery Surgery: A Trial of Hydroxyethyl Starch

Banked blood transfusion, with its attendant hazards, may be avoided in certain instances. A search for an acceptable plasma substitute was made. A randomized prospective trial of hydroxyethyl starch (HES) versus plasma for postoperative volume replacement is described. Ninety patients undergoing operations for coronary artery disease were studied over a six-month period. Ten received banked blood in the immediate postoperative period and were excluded from the study. The remaining 80 were randomized into two groups. Group 1 received plasma, and Group 2 received HES. All patients initially had autologous blood transfusion, and in 7 patients this sufficed; these patients were excluded from the study except for regression analysis. Postoperative blood loss and urine output did not differ between groups, but Group 2 patients required significantly more volume replacement ( p < 0.02). In a total of 27 patients drawn from both groups, coagulation factors and colloid osmotic pressure were investigated. There were no significant differences in fibrinogen titer and prothrombin time between groups, but return to normal values was significantly delayed in the HES group ( p < 0.01). Activated clotting time and partial thromboplastin time were unaffected. Colloid osmotic pressure was significantly higher at one week in the HES group ( p < 0.001) and was correlated with the volume of HES given ( r = 0.525; p < 0.01). There were no untoward effects attributable to HES. It is concluded that HES is a safe, cheap, and effective plasma substitute for volume replacement following cardiac surgical procedures.

Hydroxyethyl Starch versus Albumin in Cardiopulmonary Bypass Prime Solutions

To compare hydroxyethyl starch (HES) with 25% albumin, 20 patients undergoing aortocoronary bypass were randomized into two groups: 10 received 1,000 ml of HES and 10 received 200 ml of 25% albumin in a bloodless priming solution for cardiopulmonary bypass (CPB). Platelet aggregation, antithrombin III, reptilase time, fibrinogen, plasminogen, fluid requirements, and hemodynamics were monitored. Platelet aggregation was abnormal in both groups, being relatively poorer in the albumin group. Both groups exhibited below normal antithrombin III and plasminogen levels, with significantly lower antithrombin III levels noted in the HES group postoperatively (41.9 ± 11.8% versus 56.6 ± 9.9%; p = 0.006). Compared with the albumin group, the HES group had slightly, but not significantly, elevated liver function test results, total volume replacement (9,173 ± 2,046 ml versus 8,522 ± 1,192 ml; p = 0.057), packed red blood cell usage (227 ± 284 ml versus 75 ± 168 ml; p = 0.066), and chest tube drainage (599 ± 253 ml versus 454 ± 174 ml; p = 0.144). In the HES group, 5% albumin requirement was greater (386 ± 466 ml versus 50 ± 158 ml; p = 0.002) and percent increase of body weight was higher (5.2 ± 0.8% versus 2.3 ± 0.6%; p = 0.05) postoperatively. Postoperative weight increase and colloid requirements plus trends toward larger blood loss and blood transfusions indicate possible further evaluation. However, results suggest that HES is a safe additive to priming solutions. Compared with albumin, HES has comparable changes in coagulation variables and slightly less severe derangements in platelet aggregation.