The effect of 6% hydroxyethyl starch (130/0.4) on acute kidney injury in paediatric cardiac surgery: a prospective, randomised trial

Pediatric perioperative fluid management

The purpose of perioperative fluid management in children is to maintain adequate volume status, electrolyte level, and endocrine system homeostasis during the perioperative period. Although hypotonic solutions containing glucose have traditionally been used as pediatric maintenance fluids, recent studies have shown that isotonic balanced crystalloid solutions lower the risk of hyponatremia and metabolic acidosis perioperatively. Isotonic balanced solutions have been found to exhibit safer and more physiologically appropriate characteristics for perioperative fluid maintenance and replacement. Additionally, adding 1-2.5% glucose to the maintenance fluid can help prevent children from developing hypoglycemia as well as lipid mobilization, ketosis, and hyperglycemia. The fasting time should be as short as possible without compromising safety; recent guidelines have recommended that the duration of clear fluid fasting be reduced to 1 h. The ongoing loss of fluid and blood as well as the free water retention induced by antidiuretic hormone secretion are unique characteristics of postoperative fluid management that must be considered. Reducing the infusion rate of the isotonic balanced solution may be necessary to avoid dilutional hyponatremia during the postoperative period. In summary, perioperative fluid management in pediatric patients requires careful attention because of the limited reserve capacity in this population. Isotonic balanced solutions appear to be the safest and most beneficial choice for most pediatric patients, considering their physiology and safety concerns.

Higher portal venous pulsatility is associated with worse clinical outcomes following congenital heart surgery: a single-centre prospective cohort study

PURPOSE

Increased portal venous flow pulsatility is associated with major complications after adult cardiac surgery. Nevertheless, no data are available for pediatric patients with congenital heart disease. We hypothesized that Doppler parameters including portal flow pulsatility could be associated with postoperative outcomes in children undergoing various cardiac surgeries.

METHODS

We conducted a prospective observational cohort study in children undergoing congenital cardiac surgery. We obtained postoperative portal, splenic, and hepatic venous Doppler data and perioperative clinical data including major postoperative complications. Portal and splenic venous flow pulsatility were calculated. We evaluated the association between venous Doppler parameters and adverse outcomes. The primary objective was to determine whether postoperative portal flow pulsatility could indicate major complications following congenital heart surgery.

RESULTS

In this study, we enrolled 389 children, 74 of whom experienced major postoperative complications. The mean (standard deviation) portal pulsatility (44 [30]% vs 25 [14]%; 95% confidence interval [CI] for mean difference, 12 to 26; P < 0.001] and splenic pulsatility indices (41 [30]% vs 26 [16]%; 95% CI, 7 to 23; P < 0.001) were significantly higher in children with postoperative complications than in those without complications. The portal pulsatility index was able to help identify postoperative complications in biventricular patients and univentricular patients receiving bidirectional cavopulmonary shunt whereas it did not in other univentricular patients. An increased postoperative portal pulsatility index was significantly associated with major complications after pediatric cardiac surgery (odds ratio, 1.40; 95% CI, 1.29 to 1.91; P < 0.001).

CONCLUSIONS

Higher portal venous pulsatility is associated with major postoperative complications in children undergoing cardiac surgery. Nevertheless, more data are needed to conclude the efficacy of portal venous pulsatility in patients with univentricular physiology.

STUDY REGISTRATION

ClinicalTrials.gov (NCT03990779); registered 19 June 2019.

Postoperative coagulopathy among otherwise healthy pediatric patients undergoing open craniosynostosis repair: a retrospective study

Significant blood loss and resultant transfusion may lead to coagulopathy. The need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant, yet controlled, intra-operative blood loss is controversial. Open craniosynostosis surgery is often associated with significant intra-operative blood loss and transfusion, and routinely preformed on otherwise healthy pediatric patients. Therefore, we found it as a useful model for our study, which aimed to assess the need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant intra-operative blood loss. We conducted a retrospective cohort study of otherwise healthy pediatric patients, undergoing open craniosynostosis surgery and transfused solely with packed red blood cells (pRBCs) in a single large-volume tertiary surgical center, between January 2010 and December 2021. Among 457 eligible patients, 34 (7.4%) developed significant postoperative coagulopathy. Median [IQR] intra-operative pRBC transfusion volume was 17.4 ml kg^-1 [13.3, 23.1]. Patients who developed coagulopathy did not have higher postoperative pRBC transfusion rate (8.8% vs 3.8%, P = 0.16) or volume (median [IQR], 0 [0, 0] vs 0 [0, 0] ml, P = 0.15), nor higher hospital LOS (5 [4, 5] vs 5 [4, 5] days, P = 0.66). ICU LOS was 0.8 [0.7, 1] vs 0.7 [0.6, 0.8] days (P = 0.02), a difference of no clinical significance.  Conclusions: The incidence of significant coagulopathy after craniosynostosis surgery was low, and not associated with clinically important complications. In otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely managed solely with intravenous fluids and pRBC transfusion. What is Known: • Significant intra-operative blood loss and resultant transfusion may lead to postoperative coagulopathy. • There are potential deleterious effects from both coagulopathy and administration of blood products. What is New: • Open craniosynostosis corrective surgery is a useful model for studying coagulopathy after significant intra-operative blood loss and transfusion in otherwise healthy children. • Under certain conditions, in otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely treated with intravenous fluids and pRBC transfusion alone, with no clinically significant postoperative coagulopathy or its complications.

Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery: A Network Meta-Analysis

BACKGROUND AND OBJECTIVES

AKI is a common complication after pediatric cardiac surgery and has been associated with higher morbidity and mortality. We aimed to compare the efficacy of available pharmacologic and nonpharmacologic strategies to prevent AKI after pediatric cardiac surgery.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists of relevant articles were searched for randomized controlled trials from inception until August 2020. Random effects traditional pairwise, Bayesian network meta-analyses, and trial sequential analyses were performed.

RESULTS

Twenty randomized controlled trials including 2339 patients and 11 preventive strategies met the eligibility criteria. No overall significant differences were observed compared with control for corticosteroids, fenoldopam, hydroxyethyl starch, or remote ischemic preconditioning in traditional pairwise meta-analysis. In contrast, trial sequential analysis suggested a 80% relative risk reduction with dexmedetomidine and evidence of <57% relative risk reduction with remote ischemic preconditioning. Nonetheless, the network meta-analysis was unable to demonstrate any significant differences among the examined treatments, including also acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve probabilities showed that milrinone (76%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (70%), levosimendan (70%), aminophylline (59%), normothermic cardiopulmonary bypass (57%), and remote ischemic preconditioning (55%), although all showing important overlap.

CONCLUSIONS

Current evidence from randomized controlled trials does not support the efficacy of most strategies to prevent AKI in the pediatric population, apart from limited evidence for dexmedetomidine and remote ischemic preconditioning.

The comparison of albumin and 6% hydroxyethyl starches (130/0.4) in cardiac surgery: a meta-analysis of randomized controlled clinical trials

Background

Fluid administration is a key tool in the maintenance of normovolemia in patients with cardiac surgery. The trials that evaluated the safety of 6% hydroxyethyl starch (HES) 130/0.4 in cardiac surgical patients were inconsistent. It is necessary to compare the efficacy and safety of albumin and 6% HES (130/0.4).

Method

We searched for the randomized controlled clinical trials that compared human albumin with 6% HES (130/0.4) in cardiac surgery in PubMed, Cochrane, and Embase.

Results

Ten studies involved a total of 1567 patients were included in our meta-analysis. For the efficiency, there was no difference in total volume of infusion between compared groups [P = 0.64, Fixed Effect Model (FEM): standardized mean difference (SMD) = 0.04, 95% confidence interval (CI) (− 0.12, 0.20)]. As for safety, the albumin show more risk than hydroxyethyl starch 130/0.4 in blood loss [P = 0.02, FEM: SMD: 0.22, 95% CI (0.03, 0.41)]. There was no difference in the frequency of transfusions (P = 0.20, RR = 1.11; 95% CI (0.95, 1.27)) between the two groups. No difference was observed for the days in intensive care unit [P = 0.05, FEM: SMD = − 0.18, 95% CI (− 0.36, 0.00)], and the days in hospital [P = 0.32, FEM: SMD = − 0.11, 95% CI (− 0.32, 0.10)]. Furthermore, both the incidence of AKI, RRT, and mortality were comparable in the two groups.

Conclusion

This study provided evidence that the 6% HES (130/0.4) might be the substitute for HA, which reduced the economic burden for patients with cardiac surgery. However, the effect of 6% HES (130/0.4) and HA on AKI still needs to be further studied.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01340-x.

Safety and efficacy of tetrastarches in surgery and trauma: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hydroxyethyl starch (HES) 130 is a frequently used fluid to replace intravascular losses during surgery or trauma. In the past years, several trials performed in critically ill patients have raised questions regarding the safety of this product. Our aim in this meta-analysis was to evaluate the safety and efficacy of 6% HES during surgery and in trauma.

METHODS

This systematic review and meta-analysis was registered at PROSPERO (CRD42018100379). We included 85 fully published articles from 1980 to June 2018 according to the protocol and three additional recent articles up to June 2020 in English, French, German, and Spanish reporting on prospective, randomised, and controlled clinical trials applying volume therapy with HES 130/0.4 or HES 130/0.42, including combinations with crystalloids, to patients undergoing surgery. Comparators were albumin, gelatin, and crystalloids only. A meta-analysis could not be performed for the two trauma studies as there was only one study that reported data on endpoints of interest.

RESULTS

Surgical patients treated with HES had lower postoperative serum creatinine (P<0.001) and showed no differences in renal dysfunction, renal failure, or renal replacement therapy. Although there was practically no further difference in the colloids albumin or gelatin, the use of HES improved haemodynamic stability, reduced need for vasopressors (P<0.001), and decreased length of hospital stay (P<0.001) compared with the use of crystalloids alone.

CONCLUSIONS

HES was shown to be safe and efficacious in the perioperative setting. Results of the present meta-analysis suggest that when used with adequate indication, a combination of intravenous fluid therapy with crystalloids and volume replacement with HES as colloid has clinically beneficial effects over using crystalloids only.

Current Concepts in Fluid Therapy in Horses

Despite the frequent inclusion of fluid therapy in the treatment of many conditions in horses, there are limited studies available to provide evidenced-based, species-specific recommendations. Thus, equine fluid therapy is based on the application of physiology and extrapolation from evidence in other veterinary species and human medicine. The physiologic principles that underly the use of fluids in medicine are, at first glance, straightforward and simple to understand. However, in the past 20 years, multiple studies in human medicine have shown that creating recommendations based on theory in combination with experimental and/or small clinical studies does not consistently result in best practice. As a result, there are ongoing controversies in human medicine over fluid types, volumes, and routes of administration. For example, the use of 0.9% NaCl as the replacement fluid of choice is being questioned, and the theoretical benefits of colloids have not translated to clinical cases and negative effects are greater than predicted. In this review, the current body of equine research in fluid therapy will be reviewed, connections to the controversies in human medicine and other veterinary species will be explored and, where appropriate, recommendations for fluid therapy in the adult horse will be made based on the available evidence. This review is focused on the decisions surrounding developing a fluid plan involving crystalloids, synthetic colloids, and plasma.

Effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patients: a randomised controlled trial

Whether third‐generation hydroxyethyl starch solutions provoke kidney injury or haemostatic abnormalities in patients having cardiac surgery remains unclear. We tested the hypotheses that intra‐operative administration of a third‐generation starch does not worsen postoperative kidney function or haemostasis in cardiac surgical patients compared with human albumin 5%. This triple‐blind, non‐inferiority, clinical trial randomly allocated patients aged 40–85 who underwent elective aortic valve replacement, with or without coronary artery bypass grafting, to plasma volume replacement with 6% starch 130/0.4 vs. 5% human albumin. Our primary outcome was postoperative urinary neutrophil gelatinase‐associated lipocalin concentrations, a sensitive and early marker of postoperative kidney injury. Secondarily, we evaluated urinary interleukin‐18; acute kidney injury using creatinine RIFLE criteria, coagulation measures, platelet count and function. Non‐inferiority (delta 15%) was assessed with correction for multiple comparisons. We enrolled 141 patients (69 starch, 72 albumin) as planned. Results of the primary analysis demonstrated that postoperative urine neutrophil gelatinase‐associated lipocalin (median (IQR [range])) was slightly lower with hydroxyethyl starch (5 (1–68 [0–996]) ng.ml⁻¹) vs. albumin (5 (2–74 [0–1604]) ng.ml⁻¹), although not non‐inferior [ratio of geometric means (95%CI) 0.91 (0.57, 1.44); p = 0.15] due to higher than expected variability. Urine interleukin‐18 concentrations were reduced, but interleukin‐18 and kidney injury were again not non‐inferior. Of 11 individual coagulation measures, platelet count and function, nine were non‐inferior to albumin. Two remaining measures, thromboelastographic R value and arachidonic acid‐induced platelet aggregation, were clinically similar but with wide confidence intervals. Starch administration during cardiac surgery produced similar observed effects on postoperative kidney function, coagulation, platelet count and platelet function compared with albumin, though greater than expected variability and wide confidence intervals precluded the conclusion of non‐inferiority. Long‐term mortality and kidney function appeared similar between starch and albumin.

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.