ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Durand, M.
Right arrow Articles by Chavanon, O.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Durand, M.
Right arrow Articles by Chavanon, O.
Related Collections
Right arrow Extracorporeal circulation

Ann Thorac Surg 2003;75:1682-1683
© 2003 The Society of Thoracic Surgeons

Correspondence

Does hydroxyethyl starch increase blood loss in cardiac operations

Michel Durand, MDa, Olivier Chavanon, MDb

a Réanimation Cardiovasculaire et Thoracique CHU Grenoble, BP 217 Grenoble Cedex 9, France
b Service de Chirurgie Cardiaque CHU Grenoble, BP 217 Grenoble Cedex 9, France

e-mail: mdurand{at}chu-grenoble.fr
e-mail: mdurand{at}chu-grenoble.fr

To the Editor:

We read with great interest the article by Wilkes and co-workers [1] about the use of albumin versus hydroxyethyl starch (HES) in cardiac operations. This meta-analysis dealt with the effect of albumin and HES on bleeding in cardiac surgical procedures, a fundamental subject. Classically, HES has a deleterious effect in vitro on blood coagulation, whereas albumin usually has no effect [2]. Conversely, several prospective studies found no effect of HES on blood loss after noncardiac-related or cardiac operations [3]. Systematic review and a meta-analysis of these data could provide an answer to this important issue.

The authors concluded that the use of albumin was associated with significantly less bleeding than HES. However, their results merit a few comments. First, the effect of HES on blood coagulation depends on its molecular weight and its rate of elimination. Thus, not stratifying the results of HES preparations of differing molecular weights in a conclusion may cause confusion, especially in Europe where only low molecular weight HES (240 kDa or less) is used. The comparison between albumin and low molecular weight HES groups does not appear significant (standardized mean difference, -0.21 [95% confidence interval, -0.44 to 0.01], Fig 2 [1]).

The second point concerns methodology. Calculating the proportion of patients with a postoperative blood loss of more than 1,000 mL assumes that the distribution of postoperative bleeding is normal. However, in clinical practice, this distribution is usually not symmetrical, and using this rate (percentage of patients with bleeding > 1,000 mL) to compare two groups of patients is not statistically correct. In a large study [4], despite a higher mean blood loss (887 ± 747 mL) than in the two groups of this meta-analysis (693 ± 350 mL in the albumin group, 789 ± 487 mL in the HES group), the observed percentage of patients who had a blood loss greater than 1,000 mL was 29%. This result is not compatible with the estimated percentage in the study by Wilkes and associates [1], ie, 19% in the albumin group and 33% in the HES group.

Third, a 90-mL difference in chest tube drainage is probably not clinically important [5] and is not associated with increased need of blood transfusion.

In conclusion, using low molecular weight HES as practiced in Europe remains useful and safe, particularly compared with the cost of albumin.

References

  1. Wilkes M.M., Navickis R.J., Sibbald W.J. Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding. Ann Thorac Surg 2001;72:527-534.[Abstract/Free Full Text]
  2. Boldt J. Volume replacement in the surgical patient—does the type of solution make a difference. Br J Anaesth 2000;84:783-793.[Free Full Text]
  3. De Jonge E., Levi M. Effects of different plasma substitutes on blood coagulation: a comparative review. Crit Care Med 2001;29:1261-1267.[Medline]
  4. Bélisle S., Hardy J.-F. Hemorrhage and the use of blood products after adult cardiac operations: myths and realities. Ann Thorac Surg 1996;62:1908-1917.[Abstract/Free Full Text]
  5. Kapper S.M., Giesecke T., Limpers P., Sabatowski R., Mehlhorn U., Dienfenbach C. Failure of autologous fresh frozen plasma to reduce blood loss and transfusion requirements in coronary artery bypass surgery. Anesthesiology 2001;95:81-86.[Medline]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Durand, M.
Right arrow Articles by Chavanon, O.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Durand, M.
Right arrow Articles by Chavanon, O.
Related Collections
Right arrow Extracorporeal circulation

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS