Effect of hydroxyethyl starch on postoperative kidney function in patients having noncardiac surgery. Anesthesiology. 2014;121:730-739. [PMID: 25054470 DOI: 10.1097/aln.0000000000000375]

ENGINEERED INTRAVENOUS THERAPIES FOR TRAUMA

Trauma leading to severe hemorrhage and shock on average kills patients within 3 to 6 hours after injury. With average prehospital transport times reaching 1-6 hours in low- to middle-income countries, stopping the bleeding and reversing hemorrhagic shock is vital. First-generation intravenous hemostats rely on traditional drug delivery platforms, such as self-assembling systems, fabricated nanoparticles, and soluble polymers due to their active targeting, biodistribution, and safety. We discuss some challenges translating these therapies to patients, as very few have successfully made it through preclinical evaluation in large-animals, and none have translated to the clinic. Finally, we discuss the physiology of hemorrhagic shock, highlight a new low volume resuscitant (LVR) PEG-20k, and end with considerations for the rational design of LVRs.

Association between intraoperative starch use and postoperative kidney dysfunction in patients undergoing major gastro-intestinal surgery: A propensity score-matched analysis

BACKGROUND

The impact of intraoperative starch-based fluid therapy on postoperative kidney dysfunction in patients undergoing major abdominal surgery is uncertain. Low molecular weight starch is expected to cause less postoperative kidney dysfunction.

METHODS

This retrospective study evaluated the impact of intraoperative 6% hydroxyethyl starch on postoperative renal dysfunction. The primary outcome of this study was postoperative acute kidney injury as per KDIGO definition within 72 hours of surgery.

RESULTS

This study analysed data from 461 patients with a median (interquartile range) age of 45 (33-58) years, and 48.2% of all patients were female. The proportion (95% confidence interval) of patients who developed acute kidney injury was 0.18 (0.14-0.21); 62.9% of patients had acute kidney injury stage I, 32% had acute kidney injury stage II, and the rest were acute kidney injury stage III. In the propensity score-matched sample, the average treatment effect of intraoperative colloid use on postoperative serum creatinine at day 3 (p = 0.32), duration of postoperative intensive care unit stay (p = 0.97), duration of hospital stay (p = 0.37), postoperative worst international normalised ratio (p = 0.92), and postoperative transfusion requirement (p = 0.40) were not statistically significant.

CONCLUSION

Intraoperative use of low molecular weight hydroxyethyl starch use was not associated with postoperative kidney dysfunction and coagulopathy in adult patients undergoing major open abdominal surgery.

The effects of hydroxyethyl starch 130/0.4 on perioperative renal function in patients undergoing cardiac surgery: A randomised controlled trial

Background

Acute kidney injury (AKI) after cardiac surgery increases the risk of morbidity and mortality. Hydroxyethyl starch (HES) is often used during surgery due to its plasma-volume expanding effect, but the impact of HES 130/0.4 on renal function in patients undergoing cardiac surgery remains unclear. The aim of our study is to investigate the impact of HES 130/0.4 on postoperative renal function in patients undergoing cardiac surgery using cardiopulmonary bypass.

Methods

Our study was a randomised, single-center, single-blind study conducted on 60 adult patients who underwent cardiac surgery using cardiopulmonary bypass: 30 patients were intraoperatively administered with HES 130/0.4; the other 30 with Ringer's bicarbonate. The primary endpoints were occurrence of AKI within 30 days of surgery and the disease stages.

Results

The mean dose of 6% HES 130/0.4 was 28 ml/kg. AKI occurred within 30 days of the operation in 8 cases (28.6%) in the HES group and 6 cases (21.4%) in the crystalloid group (no significance: p = 0.5371). Disease stages were as follows: “no AKI”, “stage 1”, “stage 2″ and “stage 3″, accounting for 20 cases (71.5%), 6 cases (21,4%), 2 cases (7.1%), and 0 cases, respectively, in the HES group, and 22 cases (78.6%), 6 cases (21.4%), 0 cases, and 0 cases, respectively, in the crystalloid group (no significance: p = 0.3508).

Conclusion

There was no significant difference in the occurrences or stages of AKI during the 30 days following cardiac surgery with cardiopulmonary bypass between patients administered with HES 130/0.4 or Ringer's bicarbonate.

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Hydroxyethyl starch 130/0.4 is an effective plasma-volume expander.

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Hydroxyethyl starch has a potential renal toxicity in cardiac surgery.

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Acute kidney injury after cardiac surgery increases the risk of mortality.

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Administration of hydroxyethyl starch 130/0.4 or crystalloid in cardiac surgery.

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No difference in the occurrences or stages of acute kidney injury between groups.

Association of skeletal muscle index with postoperative acute kidney injury in living donor hepatectomy: A retrospective single-centre cohort study

BACKGROUND

Although living donor liver transplantation (LDLT) is the standard treatment option for patients with end-stage liver disease, it always entails ethical concerns about the risk of living donors. Recent studies have reported a correlation between sarcopenia and surgical prognosis in recipients. However, there are few studies of donor sarcopenia and the surgical prognosis of donors. This study investigated the association between sarcopenia and postoperative acute kidney injury in liver donors.

METHODS

This retrospective study analysed 2892 donors who underwent donor hepatectomy for LDLT between January 2008 and January 2018. Sarcopenia was classified into pre-sarcopenia and severe sarcopenia, which were determined to be -1 standard deviation (SD), and -2 SD from the mean baseline of the skeletal muscle index, respectively. Multivariate regression analysis was performed to evaluate the association between donor sarcopenia and postoperative AKI. Additionally, we assessed the association between donor sarcopenia and delayed recovery of liver function (DRHF).

RESULTS

In the multivariate analysis, donor sarcopenia was significantly associated a higher incidence of postoperative AKI (adjusted odds ratio [OR]: 2.65, 95% confidence interval [CI]: 1.15-6.11, P = .022 in pre-sarcopenia, OR: 5.59, 95% CI: 1.11-28.15, P = .037 in severe sarcopenia, respectively). Additionally, hypertension and synthetic colloid use were significantly associated with postoperative AKI. In the multivariate analysis, risk factors of DRHF were male gender, indocyanine green retention rate at 15 minutes, and graft type, however, donor sarcopenia was not a risk factor.

CONCLUSIONS

Donor sarcopenia is associated with postoperative AKI following donor hepatectomy.

Stage 1-Biomarkers of Kidney Injury in Dogs Undergoing Constant Rate Infusion of Hydroxyethyl Starch 130/0.4

In veterinary medicine, investigations relating the effects of hydroxyethyl starch (HES) on renal function report contrasting results. This study aimed to assess the changes in the selected biomarkers of kidney injury in dogs after the administration of HES 130/0.4 as a constant rate infusion (CRI) for 24 h. Ten adult client-owned dogs with hypoalbuminemia (albumin < 2 g/dL) and ongoing fluid losses were included. Enrolled dogs received intravenous fluid therapy with crystalloids and a CRI of HES 130/0.4 at a dose of 2 mL/kg/h for 24 h. Serum creatinine (sCr), fractional excretion (FE) of electrolytes, urinary protein to creatinine ratio (UPC), urinary albumin to creatinine ratio (UAC), SDS-page, and urinary neutrophil gelatinase-associated lipocalin (uNGAL) were measured at the baseline before HES infusion, and after 24 h (T24) and 48 h (T48) from the baseline. No statistically significant difference was found between the baseline value vs. T24 and the baseline vs. T48 for sCr, UAC, UPC, FE of sodium, chloride and calcium, and uNGAL. A significant increase in FEK (p = 0.04) was noticed between the baseline and T48. In this study sample of hypoalbuminemic dogs, HES 130/0.4 at the dose and rate of infusion applied did not cause any significant changes in the investigated biomarkers of kidney injury.

Association of Preoperative Prognostic Nutritional Index and Postoperative Acute Kidney Injury in Patients Who Underwent Hepatectomy for Hepatocellular Carcinoma

Various biological indicators are reportedly associated with postoperative acute kidney injury (AKI) in the surgical treatment of hepatocellular carcinoma (HCC). However, only a few studies have evaluated the association between the preoperative prognostic nutritional index (PNI) and postoperative AKI. This study evaluated the association of the preoperative PNI and postoperative AKI in HCC patients. We retrospectively analyzed 817 patients who underwent open hepatectomy between December 2007 and December 2015. Multivariate regression analysis was performed to evaluate the association between the PNI and postoperative AKI. Additionally, we evaluated the association between the PNI and outcomes such as postoperative renal replacement therapy (RRT) and mortality. Cox regression analysis was performed to assess the risk factors for one-year and five-year mortality. In the multivariate analysis, high preoperative PNI was significantly associated with a lower incidence of postoperative AKI (odds ratio (OR): 0.92, 95% confidence interval (CI): 0.85 to 0.99, p = 0.021). Additionally, diabetes mellitus and the use of synthetic colloids were significantly associated with postoperative AKI. PNI was associated with postoperative RRT (OR: 0.76, 95% CI: 0.60 to 0.98, p = 0.032) even after adjusting for other potential confounding variables. In the Cox regression analysis, high PNI was significantly associated with low one-year mortality (Hazard ratio (HR): 0.87, 95% CI: 0.81 to 0.94, p < 0.001), and five-year mortality (HR: 0.93, 95% CI: 0.90–0.97, p < 0.001). High preoperative PNI was significantly associated with a lower incidence of postoperative AKI and low mortality. These results suggest that the preoperative PNI might be a predictor of postoperative AKI and surgical prognosis in HCC patients undergoing open hepatectomy.

Effects of IV Fluids in Dogs and Cats With Kidney Failure

Intravenous fluid therapy has long been the mainstay of treatment of kidney disease, including acute kidney injury and uremic crisis associated with chronic kidney disease. Careful management of fluid dose is critical, as animals with kidney disease may have marked derangements in their ability to regulate fluid homeostasis and acid-base status. Understanding of the physiology of renal fluid handling is necessary, along with repeated attention to parameters of fluid status, electrolytes, and acid-base balance, to achieve optimal hydration status and avoid further damage or decrease in function from dehydration or overhydration.

Comparison of the Effects of Laparoscopic and Open Surgery on Postoperative Acute Kidney Injury in Patients with Colorectal Cancer: Propensity Score Analysis

Postoperative acute kidney injury (AKI) is a serious complication that increases patient morbidity and mortality. However, few studies have evaluated the effect of laparoscopic surgery on postoperative AKI. This study compared the incidence of postoperative AKI between laparoscopic and open surgery in patients with colorectal cancer. This study retrospectively analyzed 3637 patients who underwent colorectal cancer surgery between June 2008 and February 2012. The patients were classified into laparoscopic (n = 987) and open (n = 2650) surgery groups. We performed multivariable regression analysis to assess the risk factors for AKI and propensity score matching analysis to compare the incidence of AKI between the two groups. We also assessed postoperative intensive care unit (ICU) admission, complications, hospital stay, and 1-year mortality. We observed no significant differences in the incidence of postoperative AKI between the two groups before (8.8% vs. 9.1%, p = 0.406) and after (8.8% vs. 7.7%, p = 0.406) matching. Laparoscopic surgery was not associated with AKI even after adjusting for intraoperative variables (adjusted odds ratio (OR): 1.17, 95% confidence interval (CI): 0.84-1.62, p = 0.355). Body mass index, diabetes mellitus, hypertension, and albumin were risk factors for AKI. ICU admission (0.6% vs. 2.5%, p = 0.001), complications (0.2% vs. 1.5%, p = 0.002), hospital stay (6.89 days vs. 8.61 days, p < 0.001), and 1-year mortality (0.1% vs. 0.9%, p = 0.021) were significantly better in the laparoscopic than in the open group. The incidence of postoperative AKI did not differ significantly between laparoscopic and open surgery. However, considering its better surgical outcomes, laparoscopic surgery may be recommended for patients with colorectal cancer.

Effects of hydroxyethyl starch and gelatin on the risk of acute kidney injury following orthotopic liver transplantation: A multicenter retrospective comparative clinical study

Objectives

This multicenter retrospective study aimed to compare the effects of HES and gelatin (GEL) on the risk of post-OLT AKI.

Method

A total of 1,672 patients undergoing OLT were enrolled from major transplant centers in China between 2005 and 2013. These patients were divided into three groups: GEL, hydroxyethyl starch (HES), and GEL + HES group.

Results

There was no significant difference in the incidence of post-OLT AKI among the GEL, HES, and GEL + HES groups. The GEL + HES group had a lower incidence of stage II post-OLT AKI than the other two groups. Compared with patients receiving GEL, patients receiving HES did not harbor an increased risk of AKI. Our results showed that MELD score (adjusted odds ratio [OR], 1.579; 95% confidence interval [CI], 1.123–2.219; P = 0.009) and preoperative anemia (adjusted OR, 1.533; 95% CI, 1.212–1.939; P < 0.001) were independent risk factors for post-OLT AKI, and normal preoperative Scr level (vs abnormal; adjusted OR, 0.402; 95% CI, 0.222–0.729; P = 0.003) was independent protective factors for post-OLT AKI.

Conclusion

This large-scale multicenter retrospective study found that the intraoperative use of HES did not increase the overall incidence of post-OLT AKI in patients when compared with GEL, and whether to increase the risk of post-OLT AKI needs to be further explored.

The impact of total intravenous anesthesia versus inhalation anesthesia on acute kidney injury after major abdominal surgery: a propensity score analysis

PURPOSE

The effect of anesthetic types on postoperative acute kidney injury (AKI) remains unclear particularly in patients undergoing non-cardiac surgery. The purpose of this retrospective study was to compare total intravenous anesthesia (TIVA) and inhalation anesthesia in terms of the risk of AKI after open major abdominal surgery (MAS).

METHODS

Adult patients who underwent open MAS (gastrectomy, hepatectomy, colectomy, or pancreatectomy) at our institute from 2016 to 2018 were included. Using the multivariable logistic regression, the risk of postoperative AKI was compared among patients who underwent TIVA (TIVA group) and inhalation anesthesia (inhalation group) both in the total cohort and in the propensity score-matched cohort. Additional multivariable logistic regression analysis was performed with inverse probability of treatment weighting (IPTW) using the propensity score.

RESULTS

In total, 3616 patients were analyzed. The incidence of postoperative AKI was 5.0% (77/1546) and 7.8% (161/2070) in the TIVA and inhalation groups, respectively. The risk of AKI was significantly higher in the inhalation group [adjusted odds ratio (aOR) 1.72; 95% confidence interval (CI) 1.27-2.35; P = 0.002] than the TIVA group. In the matched cohort (n = 1518 in each group), the inhalation group also had a higher risk of AKI (aOR 1.66; 95% CI 1.20-2.31; P = 0.002). The multivariable logistic regression with IPTW showed similar results (aOR 1.59; 95% CI 1.30-1.95; P < 0.001).

CONCLUSIONS

The risk of AKI after open MAS differed significantly according to the anesthetic used. Patients receiving inhalation anesthesia may have a greater risk of postoperative AKI than those undergoing TIVA.

Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature

BACKGROUND

Over-resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature.

METHODS

A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020.

RESULTS

Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids.

CONCLUSIONS

In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.

Renal Morbidity of 6% Hydroxyethyl Starch 130/0.4 in 9000 Propensity Score Matched Pairs of Surgical Patients

BACKGROUND

Several studies of critically ill patients reported that fluid resuscitation with hydroxyethyl starch (HES) solutions damages the kidneys, but their use for surgical patients is debated. Because different HES preparations have different safety profiles, we sought to determine whether 6% third-generation HES 130/0.4 was associated with renal morbidity when used for surgical patients.

METHODS

We identified adults enrolled in a Japanese nationwide medical database who underwent surgery between 2014 and 2016, with HES 130/0.4 or without it (controls). These groups were balanced with propensity score matching in a 1:1 ratio without replacement by multivariable logistic regression with 36 covariates, including demographic characteristics, preoperative comorbidities, and anesthetic/surgical procedures. The primary outcome was the incidence of acute kidney injury (AKI) in patients receiving intraoperative HES and controls. Secondary outcomes were assessing whether HES was associated with worsening AKI stage, the incidence of renal-replacement therapy (RRT), hospital length-of-stay, and in-hospital 30-day mortality. Tertiary outcomes include the use of vasoactive agents and the fluid requirement on the day of surgery. Comparative analysis was made with χ, Mann-Whitney U test, or the ordinal logistic regression analysis.

RESULTS

Of 76,048 patients in the database, 58,425 were eligible: 9542 received HES and 48,883 controls. Propensity score matching identified 8823 matched pairs. The incidence of AKI was 6.2% (548/8823) in the HES group and 5.6% (492/8823) in controls (odds ratio [OR], 1.12; 95% confidence interval [CI], 0.99-1.27; P = .07). Compared to controls, HES was not associated with worsening AKI stage (OR, 0.89; 95% CI, 0.79-1.01; P = .08). The incidence of RRT was lower in the HES group than that in controls (0.2% vs 0.4%, respectively; OR, 0.51; 95% CI, 0.29-0.91; P = .02). Median [interquartile range] hospital stay was 1 day longer in the HES group (12 [8-21] vs 11 [7-20] days; P < .001), but in-hospital 30-day mortality did not differ between groups (0.5% vs 0.6%, respectively: OR, 0.83; 95% CI, 0.56-1.24; P = .36). The use rate of vasoactive agents and the median net fluid requirement on the day of surgery were higher in the HES group (80.5% vs 70.0%: P < .001, 88.1 vs 73.6 mL/kg; P < .001, respectively) compared to controls.

CONCLUSIONS

The present study did not demonstrate that 6% HES 130/0.4 increased the incidence and the severity of postoperative AKI. It was associated with a lower incidence of RRT when used for surgical patients.

Understanding short bowel syndrome: Current status and future perspectives

Short bowel syndrome (SBS) is a rare malabsorptive disorder as a result of the loss of bowel mass mostly secondary to surgical resection of the small intestine. Other causes are vascular diseases, neoplasms or inflammatory bowel disease. The spectrum of the disease is widely variable from single micronutrient malabsorption to complete intestinal failure, depending on the remaining length of the small intestine, the anatomical portion of intestine and the function of the remnant bowel. Over the last years, the management of affected patients has remarkably improved with the increase in patients' quality of life and survival, mainly thanks to advances in home-based parenteral nutrition (PN). In the last ten years new treatment strategies have become available together with increasing experience and the encouraging results with new drugs, such as teduglutide, have added a new dimension to the management of SBS. This review aims to summarize the knowledge available in the current literature on SBS epidemiology, pathophysiology, and its surgical (including intestinal lengthening procedures and intestinal transplantation) and medical management with emphasis on the recent advances. Moreover, this review attempts to provide the new understanding and recent approaches to SBS complications such as sepsis, catheter thrombosis, and intestinal failure-associated liver disease.

lntraoperative administration of 6% hydroxyethyl starch 130/0.4 is not associated with acute kidney injury in elective non-cardiac surgery: A sequential and propensity-matched analysis

BACKGROUND

Intraoperative use of hydroxyethyl starch (HES) may increase the risk of postoperative acute kidney injury (AKI). Data from large populations are lacking. We aimed to assess whether intraoperative administration of 6% HES 130/0.4 is associated with AKI in non-cardiac surgery.

METHODS

This retrospective study used the electronic records concerning elective abdominal, urologic, thoracic and peripheral vascular surgeries from 2010 to 2015. HES and non-HES patients were compared using a propensity score matching. Postoperative AKI, defined by stage 3 of the Kidney Disease Improving Global Outcomes (KDIGO) score, was the primary outcome. Because the use of HES markedly decreased in 2013, additional analyses, restricted to the 2010-2012 period, were also performed.

RESULTS

In total, 23,045, and 11,691 patients were included in the whole, and restricted periods, respectively. The reduction in HES use was not accompanied by any change in the incidence of AKI. Unadjusted association between HES and KDIGO 3 AKI was significant (OR [95% CI] of 2.13 [1.67, 2.71]). For the whole period, 6460 patients were matched. Odd ratios for KDIGO 3 and all-stage AKI when using HES (10.3±4.7mL.kg^-1) were 1.20 (95% CI [0.74, 1.95]), and 1.21 (95% CI [0.95, 1.54]), respectively. There was no association with the initiation of renal replacement therapy or in-hospital mortality either. Similar results were found for the restricted period.

CONCLUSION

The intraoperative use of moderate doses of 6% HES 130/0.4 was not associated with increased risk of AKI. No conclusion can be drawn for higher doses of HES.

Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure

BACKGROUND

Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown.

METHODS

A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF).

RESULTS

We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023).

CONCLUSIONS

There was a complex U‑shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

Hydroxyethyl Starch 130/0.4 and Its Impact on Perioperative Outcome: A Propensity Score Matched Controlled Observation Study

BACKGROUND

Adverse effects of hydroxyethyl starches (HESs) have been verified in patients suffering from sepsis or kidney disease, but not in surgical patients at large. The investigation aimed to determine whether the use of HES 130/0.4 was associated with the incidence of acute postinterventional adverse events compared to Ringer's acetate alone in a perioperative setting.

METHODS

This propensity score matched, controlled observational study was performed in a single-centre university hospital. The perioperative data of 9085 patients were analyzed. Group matching was based on 13 categories including demographic data, type of procedure, and 5 preexisting comorbidities. Duration of procedure and intraoperative transfusion requirements were integrated in the matching process to reduce selection and indication bias. The primary outcome was incidence of postoperative kidney failure. Secondary outcomes were in-hospital mortality, fluid requirements, blood loss, hemodynamic stability, and the need for postoperative intensive care unit (ICU) treatment.

RESULTS

The administration of HES 130/0.4 was not associated with an increased frequency of postoperative kidney failure. In-hospital mortality (Ringer's acetate: 2.58%; HES 130/0.4: 2.68%) and the need for ICU care (Ringer's acetate: 30.5%; HES 130/0.4: 34.3%) did not differ significantly between groups. Significant intergroup differences were observed for mean blood loss (Ringer's acetate: 406 ± 821 mL; HES 130/0.4: 867 ± 1275 mL; P < .001) and median length of hospital stay (Ringer's acetate: 10.5 (5/17) days; HES 130/0.4: 12.0 (8/19) days; P < .001).

CONCLUSIONS

An association between intraoperative HES therapy and postoperative kidney failure was not observed in a mixed cohort of elective surgical patients. In addition, HES 130/0.4 was not associated with an increased morbidity or the need for ICU therapy in this propensity score matched study.

Does the choice of intraoperative fluid modify abdominal aneurysm repair outcomes?: A cohort analysis

Intraoperatively administered hydroxyethyl starch could be a risk indicator for postoperative acute kidney injury (AKI) in vascular surgical patients.In a single-center retrospective cohort analysis, we assessed the impact of hydroxyethyl starch and other risk indicators on AKI and mortality in 1095 patients undergoing elective open abdominal aneurysm repair (AAA-OR) or endovascular aortic repair (EVAR). We established logistic regression models to determine the effect of various risk indicators, including hydroxyethyl starch, on AKI, as well as Cox proportional hazard models to assess the effect on mortality.The use of intravenous hydroxyethyl starch was not associated with an increased risk of AKI or mortality. Patients undergoing EVAR were less likely to develop AKI (4% vs 18%). Multivariate risk indicators associated for AKI included suprarenal or pararenal aortic cross-clamp [odds ratio (OR), 4.44; 95% confidence interval (95% CI), 2.538-7.784; P < .001] and procedure length (OR, 1.005; 95% CI, 1.003-1.007; P < .001), and favored EVAR (OR, 0.351; 95% CI, 0.118-0.654; P < .01). Main multivariate risk indicators associated with mortality included patients needing an urgent procedure [hazard ratio (HR), 2.294; 95% CI, 1.541-3.413; P < .001], those with suprarenal or pararenal aortic cross-clamp (HR, 1.756; 95% CI, 1.247-2.472; P < .01), and patients undergoing EVAR (HR, 1.654; 95% CI, 1.292-2.118; P < .001).We found neither a benefit nor a negative effect of hydroxyethyl starch on the risk of AKI or mortality. Instead, other variables and comorbidities were found to be relevant for the development of postoperative AKI and survival. Nevertheless, clinicians should be aware of the high risk of postoperative AKI, particularly among those undergoing AAA-OR procedures.

The effects of perioperative intravenous fluid administration strategy on renal outcomes in patients undergoing cardiovascular surgery: An observational study

We assessed whether perioperative fluid management with balanced solutions and a limited volume of hydroxyethyl starch (renal-protective fluid management [RPF] strategy) could improve renal outcomes after cardiovascular surgery.For this retrospective observational study, we evaluated 2613 patients who underwent cardiovascular surgery from January 1, 2010 to December 31, 2013. The control group were given intravenous fluids with saline-based solutions and unlimited volumes of hydroxyethyl starch solutions and the RPF group were given intravenous fluids with RPF. The primary outcome was the incidence of acute kidney injury (AKI) and chronic dialysis within 12 months after cardiovascular surgery. Multivariable regression and propensity analyses were performed to evaluate the association between perioperative fluid management strategy and postoperative renal outcomes.Postoperative AKI and chronic dialysis occurred in 213 (21.2%) and 5 (0.5%) patients in the RPF group compared with 696 (43.2%) and 38 (2.4%) patients in the control group, respectively. After adjustment, the RPF group was linked to a decreased risk of postoperative AKI, severe AKI, persistent AKI, use of renal replacement therapy, chronic kidney disease, chronic dialysis, and a shorter postoperative extubation time and intensive care unit, and hospital stay duration.The perioperative fluid management strategy with balanced solutions and a limited volume of hydroxyethyl starch was related to improved acute and 1-year renal and clinical outcomes after cardiovascular surgery. These findings indicate the need for further definitive clinical trials on perioperative fluid management strategy.

Understanding the Harms of HES: A Review of the Evidence to Date

Intravenous (IV) fluid resuscitation is one of the most common interventions in intensive care medicine. Despite clear guidelines, the choice of IV fluid is largely dependent on physician preference instead of high-quality evidence of efficacy and safety. This is particularly the case for synthetic colloids, such as hydroxyethyl starch (HES). The use of HES in critical care has been associated with increased rates of acute kidney injury (AKI), renal replacement therapy and mortality. In light of this, current guidelines and scientific and regulatory bodies do not recommend the use of HES for fluid therapy in critical illness and caution against its use in many other settings. Despite this, HES products are still debated and used. Awareness of the indications, contraindications, doses, benefits and adverse effects for IV fluids, as well as recommendations from scientific and regulatory bodies, is essential to guarantee patients' safety. Poor awareness of optimal IV fluid therapy has recently been revealed in some countries including Turkey. Therefore, we provide a review of fluids used for resuscitation, discuss safety data and adverse effects of HES, such as increased AKI and mortality, and discuss recent updates from scientific and regulatory bodies in order to raise awareness of fluid therapy. We conclude that given the lack of a clear benefit of HES in any clinical setting and the availability of safer alternatives, such as crystalloids and albumin, HES should be avoided.

Choice of fluids in critically ill patients

Background

Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia.

Main text

Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions.

Conclusions

The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma).

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0669-3) contains supplementary material, which is available to authorized users.

Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients.

Methods

The CRISTAL trial prospectively defined patients as critically ill surgical patients whenever they underwent emergency or scheduled surgery immediately before or within 24 h of intensive care unit admission and had hypovolemic shock. The primary outcome measure was death by day 28. Secondary outcome measures included death by day 90, the need for renal replacement therapy, or the need for fresh frozen plasma transfusion.

Results

There were 741 critically ill surgical patients, 356 and 385 in the crystalloid and colloid arm, respectively. Median (interquartile range) age was 66 (52 to 76) yr, and 484 (65.3%) patients were male. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) versus colloids 100 (26%; adjusted odds ratio, 0.86; 95% CI, 0.61 to 1.21; P = 0.768). Death by day 90 (111 [31.2%] vs. 122 [31.7%]; adjusted odds ratio, 0.97; 95% CI, 0.70 to 1.33; P = 0.919) did not significantly differ between groups. Renal replacement therapy was required for 42 (11.8%) patients in the crystalloids arm versus 49 (12.7%) in the colloids arm (P = 0.871).

Conclusions

The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.

Intestinal failure in adults: Recommendations from the ESPEN expert groups

BACKGROUND & AIMS

Intestinal failure (IF) is defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". Functionally, it may be classified as type I acute intestinal failure (AIF), type II prolonged AIF and type III chronic intestinal failure (CIF) The ESPEN Workshop on IF was held in Bologna, Italy, on 15-16 October 2017 and the aims of this document were to highlight the current state of the art and future directions for research in IF.

METHODS

This paper represents the opinion of experts in the field, based on current evidence. It is not a formal review, but encompasses the current evidence, with emphasis on epidemiology, classification, diagnosis and management.

RESULTS

IF is the rarest form of organ failure and can result from a variety of conditions that affect gastrointestinal anatomy and function adversely. Assessment, diagnosis, and short and long-term management involves a multidisciplinary team with diverse expertise in the field that aims to reduce complications, increase life expectancy and improve quality of life in patients.

CONCLUSIONS

Both AIF and CIF are relatively rare conditions and most of the published work presents evidence from small, single-centre studies. Much remains to be investigated to improve the diagnosis and management of IF and future studies should rely on multidisciplinary, multicentre and multinational collaborations that gather data from large cohorts of patients. Emphasis should also be placed on partnership with patients, carers and government agencies in order to improve the quality of research that focuses on patient-centred outcomes that will help to improve both outcomes and quality of life in patients with this devastating condition.

Comparison of acute kidney injury between open and laparoscopic pylorus-preserving pancreaticoduodenectomy: Propensity score analysis

Laparoscopic pylorus-preserving pancreaticoduodenectomy is being performed more frequently because of improved surgical techniques. Although several studies have demonstrated safety and favourable outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy compared to open pylorus-preserving pancreaticoduodenectomy, few studies have focused on the development of postoperative acute kidney injury. This retrospective study compared the prevalence and risk factors of acute kidney injury following laparoscopic and open pylorus-preserving pancreaticoduodenectomy. Data from 809 patients who underwent pylorus-preserving pancreaticoduodenectomy between February 2012 and September 2016 were analysed. Patients were divided into two groups according to the surgical procedure (open pylorus-preserving pancreaticoduodenectomy [n = 632] vs laparoscopic pylorus-preserving pancreaticoduodenectomy [n = 177]). The Kidney Disease: Improving Global Outcomes criteria were used to define postoperative acute kidney injury and risk factors were investigated using multivariable logistic regression analysis with propensity score matching analysis and standardized mortality ratio weighting to compare outcomes. No significant differences were found in the occurrence of postoperative acute kidney injury and incidence of postoperative ICU admission between open and laparoscopic pylorus-preserving pancreaticoduodenectomy groups after propensity score matching (p = 1.000, p = 0.999, respectivelyand standardized mortality ratio weighted analysis (p = 0.619, p = 0.982, respectively). Hospital stay was significantly shorter in the laparoscopic pylorus-preserving pancreaticoduodenectomy group (propensity matched set, mean [SD], 16.7 [10.0] vs. 18.7 [9.6] days, p = 0.004; standardized mortality ratio, 16.6 [9.9] vs. 18.1 [8.8] days, p = 0.001). There was no significant difference in postoperative acute kidney injury incidence between both groups. Laparoscopic pylorus-preserving pancreaticoduodenectomy is promising with comparable postoperative outcomes to open pylorus-preserving pancreaticoduodenectomy and has the advantage of shorter hospital stay.

Synthetic colloid resuscitation in severely injured patients: analysis of a nationwide trauma registry (TraumaRegister DGU)

The purpose of this study was to investigate the efficacy and safety of synthetic colloid resuscitation among severely injured patients. Fluid resuscitation of trauma patients of a nationwide trauma registry was analysed between 2002 and 2015. Effects of synthetic colloid resuscitation in the pre-hospital setting and emergency department on renal failure, renal replacement therapy and multiple organ failure were analysed among patients with ≥2 days intensive care unit stay, and in-hospital mortality was analysed among all patients. 48,484 patients with mean age of 49 years and mean injury severity score of 23 points were included; 72.3% were male and 95.5% had blunt trauma. Risk-adjusted analyses revealed that patients receiving >1,000 ml synthetic colloids experienced an increase of renal failure and renal replacement therapy rates (OR 1.42 and 1.32, respectively, both p ≤ 0.006). Any synthetic colloid use was associated with an increased risk of multiple organ failure (p < 0.001), but there was no effect on hospital mortality (p = 0.594). Between 2002 and 2015 usage of synthetic colloids dropped, likewise did total fluid intake and usage of blood products. The data from this analysis suggests that synthetic colloid resuscitation provides no beneficial effects and might be harmful in patients with severe trauma.

Update on perioperative acute kidney injury

PURPOSE OF REVIEW

In this review, we discuss the latest updates on perioperative acute kidney injury (AKI) and the specific considerations that are relevant to different surgeries and patient populations.

RECENT FINDINGS

AKI diagnosis is constantly evolving. New biomarkers detect AKI early and shed a light on the possible cause of AKI. Hypotension, even for a short duration, is associated with perioperative AKI. The debate on the deleterious effects of chloride-rich solutions is still far from conclusion. Remote ischemic preconditioning is showing promising results in the possible prevention of perioperative AKI. No definite data show a beneficiary effect of statins, fenoldepam, or sodium bicarbonate in preventing AKI.

SUMMARY

Perioperative AKI is prevalent and associated with significant morbidity and mortality. Considering the lack of effective preventive or therapeutic interventions, this review focuses on perioperative AKI: measures for early diagnosis, defining risks and possible mechanisms, and summarizing current knowledge for intraoperative fluid and hemodynamic management to reduce risk of AKI.

Organ Donor Management: Part 1. Toward a Consensus to Guide Anesthesia Services During Donation After Brain Death

Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage. The majority of organs are from deceased donors; however, some are not suitable for transplantation. Some of this loss is due to management of the donor. Improved donor care may increase the number of available organs and help close the existing gap in supply and demand. In order to address this concern, The Organ Donation and Transplantation Alliance, the Association of Organ Procurement Organizations, and the Transplant and Critical Care Committees of the American Society of Anesthesiologists have formulated evidence-based guidelines, which include a call for greater involvement and oversight by anesthesiologists and critical care specialists, as well as uniform reporting of data during organ procurement and recovery.

Risk factors for and the prevention of acute kidney injury after abdominal surgery

Postoperative acute kidney injury in patients undergoing abdominal surgery is not rare and often results in bad outcomes for patients. The incidence of postoperative acute kidney injury is hard to evaluate reliably due to its non-unified definitions in different studies. Risk factors for acute kidney injury specific to abdominal surgery include preoperative renal insufficiency, intraabdominal hypertension, blood transfusion, bowel preparation, perioperative dehydration, contrast agent and nephrotoxic drug use. Among these, preoperative renal insufficiency is the strongest predictor of acute kidney injury. The peri-operative management of high-risk patients should include meticulous selection of fluid solutions. Balanced crystalloid solutions and albumin are generally thought to be relatively safe, while the safety of hydroxyethyl starch solutions has been controversial. The purpose of the present review is to discuss the current knowledge regarding postoperative acute kidney injury in abdominal surgical settings to help surgeons make better decisions concerning the peri-operative management.

Effects of Fluid Treatment With Hydroxyethyl Starch on Renal Function in Patients With Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Recent reports have doubted the efficacy and safety of hydroxyethyl starch (HES) for volume resuscitation. HES has been reported to promote renal insufficiency particularly in sepsis and trauma patients. This analysis investigated the effects of HES 6% 130/0.4 for fluid therapy in patients with intact renal function who suffered aneurysmal subarachnoid hemorrhage (SAH).

METHODS

This retrospective analysis included 107 patients and was conducted in the framework of a clinical trial assessing the efficacy of magnesium sulfate in SAH. Because magnesium is renally eliminated, patients with renal insufficiency had been excluded. Standard therapy after aneurysm occlusion included the daily administration of HES 6% 130/0.4. Serum and urine creatinine and fluid balance were measured daily.

RESULTS

Patients received a daily mean of 1101±524 mL HES and 3353±1396 mL Ringer's solution. The highest creatinine values were recorded on day 3 after admission (0.88±0.25 mg/100 mL) and continuously decreased thereafter. In 6 patients, creatinine values temporarily increased by >0.3 mg/100 mL but recovered to admission values at the end of the observation period.

CONCLUSIONS

Concerning renal function, the first days after SAH seem to be a vulnerable phase in which a variety of interventions are performed, including contrast-enhanced neuroradiologic procedures. In this period, HES 6% 130/0.4 should be administered with caution. However, no patient suffered from renal failure and required temporary or permanent renal replacement therapy. These results suggest that the administration of HES 6% 130/0.4 is safe in SAH patients without preexisting renal insufficiency.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

To use or not to use hydroxyethyl starch in intraoperative care: are we ready to answer the 'Gretchen question'?

PURPOSE OF REVIEW

The decision of the European Medicines Agency (EMA) against the use of hydroxyethyl starch (HES)-based volume replacement solutions in critically ill patients has led to a general uncertainty when dealing with HES-based solutions, even though HES-containing solutions can still be used for the treatment of hypovolaemia caused by acute (sudden) blood loss. This review discusses current evidence of the intraoperative use of HES-based solutions.

RECENT FINDINGS

HES solutions are often criticized for possible side-effects on the kidney, the coagulation system or tissue storage. Relevant differences exist between modern 6% HES 130/0.4 and older generation of starches. Because of pathophysiological differences between elective surgery and critical illness, the evidence on renal injury and coagulation impairment with HES administration cannot be generalized. Current data suggest that there is no clinically relevant impact of 6% HES 130/0.4 administration on perioperative renal function and coagulation. Over-resuscitation is a frequent problem associated with adverse outcomes. Due to the higher volume effect, fluid overload with HES is probably more harmful than with crystalloids, whereas goal-directed use of HES may be able to reduce intraoperative fluid accumulation and overload.

SUMMARY

The use of 6% HES 130/0.4 in elective surgery patients is associated with reduced fluid accumulation and no clinically relevant difference in bleeding or the rate of acute kidney injury as compared with crystalloid use alone. Current data do not allow a conclusion on mortality. As they provide no benefit, older starch preparations should not be used.

Fluid management in living donor hepatectomy: Recent issues and perspectives

The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.

Relationship between a perioperative intravenous fluid administration strategy and acute kidney injury following off-pump coronary artery bypass surgery: an observational study

INTRODUCTION

Saline-based and hydroxyethyl starch solutions are associated with increased risk of renal dysfunction. In the present study, we tested the hypothesis that balanced solutions and a limited volume of hydroxyethyl starch solution (renal protective fluid management [RPF] strategy) would decrease the incidence of postoperative acute kidney injury (AKI) and improve clinical outcomes in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB).

METHODS

We investigated 783 patients who underwent elective OPCAB. All patients who underwent OPCAB between 1 January 2010 and 4 July 2012 formed the control group and were given intravenous fluids with saline-based solutions and unlimited volumes of colloid solutions. All patients who underwent OPCAB between 5 July 2012 and 31 December 2013 formed the RPF group and were given intravenous fluids with RPF. The primary outcome was the incidence of postoperative AKI. Secondary outcomes included the incidence of severe AKI, requirement for renal replacement therapy, renal outcome at the time of discharge, and other clinical outcomes.

RESULTS

Postoperative AKI occurred in 33 patients (14.4 %) in the RPF group compared with 210 patients (37.9 %) in the control group (P < 0.001). The incidences of severe AKI and persistent AKI after OPCAB were significantly lower, and the postoperative extubation time and duration of hospital stay were significantly shorter, in patients in the RPF group than in those in the control group. After adjustment by multivariate regression analyses and inverse probability of treatment weighting adjustment, the RPF group was independently associated with a lower incidence of postoperative AKI, severe AKI, and persistent AKI and a shorter postoperative extubation time and duration of hospital stay.

CONCLUSIONS

The RPF strategy is associated with a significantly decreased incidence of postoperative, severe, and persistent AKI in patients undergoing OPCAB, although residual confounding may be present.

The effect of 6% hydroxyethyl starch 130/0.4 on renal function, arterial blood pressure, and vasoactive hormones during radical prostatectomy: a randomized controlled trial

BACKGROUND

Although hydroxyethyl starch (HES) is commonly used as an intravascular volume expander in surgical patients, recent studies suggest that it may increase the risk of renal failure in critically ill patients. We hypothesized that patients undergoing radical prostatectomy and receiving HES would be more likely to develop markers of renal failure, such as increasing urinary neutrophil gelatinase-associated lipocalin (u-NGAL), creatinine clearance (C(crea)), and decreasing urine output (UO).

METHODS

In a randomized, double-blinded, placebo-controlled study, 40 patients referred for radical prostatectomy received either 6% HES 130/0.4 or saline 0.9%; 7.5 mL/kg during the first hour of surgery and 5 mL/kg in the following hours; u-NGAL, urine albumin, C(crea), UO, arterial blood pressure, and plasma concentrations of creatinine, renin, angiotensin II, aldosterone, and vasopressin were measured before, during, and after surgery.

RESULTS

Thirty-six patients completed the study. u-NGAL, C(crea), UO, plasma neutrophil gelatinase-associated lipocalin, p-creatinine, urine albumin, and arterial blood pressure were the same in both groups. Blood loss was higher in the HES group (HES 1250 vs saline 750 mL), while p-albumin was reduced to a significantly lower level. P-renin and p-angiotensin-II increased in both groups, whereas p-aldosterone and p-vasopressin increased significantly in the saline group.

CONCLUSIONS

We found no evidence of nephrotoxicity after infusion of 6% HES 130/0.4 in patients undergoing prostatectomy with normal preoperative renal function. Hemodynamic stability and infused fluid volume were the same in both groups. We observed an increased blood loss in the group given 6% HES 130/0.4.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

OBJECTIVE

To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.

DESIGN

Retrospective cohort study of population based data between 2006 and 2013.

SETTING

Data from 510 different hospitals across the United States participating in the Premier Perspective database.

PARTICIPANTS

1,051,441 patients undergoing elective total hip and knee arthroplasties.

EXPOSURES

Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither.

MAIN OUTCOME MEASURES

Acute renal failure and thromboembolic, cardiac, and pulmonary complications.

RESULTS

Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased.

CONCLUSIONS

Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.