1
|
Miyao H, Kotake Y. Renal Morbidity of 6% Hydroxyethyl Starch 130/0.4 in 9000 Propensity Score Matched Pairs of Surgical Patients. Anesth Analg 2020; 130:1618-1627. [PMID: 31856004 PMCID: PMC7249485 DOI: 10.1213/ane.0000000000004592] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
Collapse
Affiliation(s)
- Hideki Miyao
- From the Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, Tokyo, Japan
| |
Collapse
|
2
|
Ünal MN, Reinhart K. Understanding the Harms of HES: A Review of the Evidence to Date. Turk J Anaesthesiol Reanim 2019; 47:81-91. [PMID: 31080948 DOI: 10.5152/tjar.2019.72681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/26/2018] [Indexed: 12/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- M Necmettin Ünal
- Department of Anaesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Konrad Reinhart
- Department of Anaesthesiology and Intensive Care Medicine, Centre for Sepsis Care and Control, Jena University Hospital, Jena, Germany
| |
Collapse
|
3
|
Breil T, Boettcher M, Hoffmann GF, Ries M. Publication status of completed registered studies in paediatric appendicitis: a cross-sectional analysis. BMJ Open 2018; 8:e021684. [PMID: 30012791 PMCID: PMC6082464 DOI: 10.1136/bmjopen-2018-021684] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Appendicitis is considered the most frequent surgical emergency in children. While the management of paediatric appendicitis is evolving, the precise amount of unpublished completed trials, potentially introducing bias into meta-analyses, is unknown. Controversial issues include the appropriate choice of surgical procedures, criteria for diagnosis of appendicitis, the role of antibiotic treatment and pain management. Selective reporting may introduce bias into evidence-based clinical decision-making, and the current, precise extent of unpublished results in paediatric appendicitis is unknown. We therefore assessed the publication status of completed clinical studies involving children registered on ClinicalTrials.gov. DESIGN Cross sectional analysis. STrengthening the Reporting of OBservational studies in Epidemiology criteria were applied for design and analysis. SETTING AND PARTICIPANTS ClinicalTrials.gov was queried for completed studies which were matched to publications on ClinicalTrials.gov, PubMed or Google Scholar. If no publication could be identified, principal investigators were contacted. INTERVENTIONS/EXPOSURE Observational analysis. PRIMARY AND SECONDARY OUTCOME MEASURES The proportion of published and unpublished studies was calculated. Subgroup analysis included studies on surgical procedures, diagnosis, antibiotic treatment and pain management. RESULTS Out of n=52 completed clinical studies involving children with appendicitis, n=33 (63%) were published and n=19 (37%) were unpublished. Eighty-three per cent (n=43/52) of clinical trials assessed the above-listed controversial issues. Diagnostic studies were most rigorously published (91% of trials reported), data on surgical procedures, antibiotic and pain management were less transparent. Sixty-six per cent of interventional studies and 60% of randomised studies were published. Median time-to-publication, for example, the delay between completion of the trial until public availability of the results was 24 (IQR 12-36), range 2-92 months. CONCLUSION Despite the importance of appendicitis in clinical practice for the paediatric surgeon, there remains scientific uncertainty due to unpublished clinical trial results with room for improvement in the future. These data are helpful in framing the shifting paradigms in paediatric appendicitis because it adds transparency to the debate.
Collapse
Affiliation(s)
- Thomas Breil
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Boettcher
- Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Georg F Hoffmann
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Ries
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
4
|
Hilbert-Carius P, Wurmb T, Lier H, Fischer M, Helm M, Lott C, Böttiger BW, Bernhard M. [Care for severely injured persons : Update of the 2016 S3 guideline for the treatment of polytrauma and the severely injured]. Anaesthesist 2017; 66:195-206. [PMID: 28138737 DOI: 10.1007/s00101-017-0265-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In 2011 the first interdisciplinary S3 guideline for the management of patients with serious injuries/trauma was published. After intensive revision and in consensus with 20 different medical societies, the updated version of the guideline was published online in September 2016. It is divided into three sections: prehospital care, emergency room management and the first operative phase. Many recommendations and explanations were updated, mostly in the prehospital care and emergency room management sections. These two sections are of special interest for anesthesiologists in field emergency physician roles or as team members or team leaders in the emergency room. The present work summarizes the changes to the current guideline and gives a brief overview of this very important work.
Collapse
Affiliation(s)
- P Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Schmerztherapie, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Str. 165, 06112, Halle (Saale), Deutschland.
| | - T Wurmb
- Sektion Notfall- und Katastrophenmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - H Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln, Köln, Deutschland
| | - M Fischer
- Klinik für Anästhesiologie und Intensivmedizin, Klinik am Eichert, ALB FILS KLINIKEN GmbH, Göppingen, Deutschland
| | - M Helm
- Klinik für Anästhesiologie & Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - C Lott
- Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - B W Böttiger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln, Köln, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| |
Collapse
|
5
|
Fischer-Fröhlich CL, Kutschmann M, Feindt J, Schmidtmann I, Kirste G, Frühauf NR, Wirges U, Rahmel A, Schleicher C. Influence of Deceased Donor and Pretransplant Recipient Parameters on Early Overall Kidney Graft-Survival in Germany. J Transplant 2015; 2015:307230. [PMID: 26539298 PMCID: PMC4619958 DOI: 10.1155/2015/307230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/03/2015] [Indexed: 12/02/2022] Open
Abstract
Background. Scarcity of grafts for kidney transplantation (KTX) caused an increased consideration of deceased donors with substantial risk factors. There is no agreement on which ones are detrimental for overall graft-survival. Therefore, we investigated in a nationwide multicentre study the impact of donor and recipient related risks known before KTX on graft-survival based on the original data used for allocation and graft acceptance. Methods. A nationwide deidentified multicenter study-database was created of data concerning kidneys donated and transplanted in Germany between 2006 and 2008 as provided by the national organ procurement organization (Deutsche Stiftung Organtransplantation) and BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 4411, isolated KTX). Results. Risk factors associated with graft-survival were donor age (1.020 [1.013-1.027] per year), donor size (0.985 [0.977-0.993] per cm), donor's creatinine at admission (1.002 [1.001-1.004] per µmol/L), donor treatment with catecholamine (0.757 [0.635-0.901]), and reduced graft-quality at procurement (1.549 [1.217-1.973]), as well as recipient age (1.012 [1.003-1.021] per year), actual panel reactive antibodies (1.007 [1.002-1.011] per percent), retransplantation (1.850 [1.484-2.306]), recipient's cardiovascular comorbidity (1.436 [1.212-1.701]), and use of IL2-receptor antibodies for induction (0.741 [0.619-0.887]). Conclusion. Some donor characteristics persist to impact graft-survival (e.g., age) while the effect of others could be mitigated by elaborate donor-recipient match and care.
Collapse
Affiliation(s)
| | - Marcus Kutschmann
- BQS Institute for Quality and Patient Safety, Kanzlerstraße 4, 40472 Düsseldorf, Germany
| | - Johanna Feindt
- MVZ Anaesthesio Nordrhein, Hans-Günther-Sohl-Straße 6-10, 40235 Düsseldorf, Germany
| | - Irene Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Obere Zahlbacher Straße 69, 55131 Mainz, Germany
| | - Günter Kirste
- Medizinische Fakultät, Albert Ludwigs Universität Freiburg, Hebelstraße 29, 79104 Freiburg, Germany
| | - Nils R. Frühauf
- Landesärztekammer Niedersachsen, Berliner Allee 20, 30175 Hannover, Germany
| | - Ulrike Wirges
- Deutsche Stiftung Organtransplantation, Region Nordrhein-Westfalen, Lindenallee 29-41, 45127 Essen, Germany
| | - Axel Rahmel
- Deutsche Stiftung Organtransplantation, Deutschherrnufer 52, 60594 Frankfurt am Main, Germany
| | - Christina Schleicher
- Deutsche Stiftung Organtransplantation, Region Baden-Württemberg, Kriegerstraße 6, 70192 Stuttgart, Germany
| |
Collapse
|
6
|
Datta R, Nair R, Pandey A, Kumar N, Sahoo T. Hydroxyeyhyl starch: Controversies revisited. J Anaesthesiol Clin Pharmacol 2014; 30:472-80. [PMID: 25425769 PMCID: PMC4234780 DOI: 10.4103/0970-9185.142801] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Hydroxyethyl starch (HES) family has been one of the cornerstones in fluid management for over four decades. Recent evidence from clinical studies and meta-analyses has raised few concerns about the safety of these fluids, especially in certain subpopulations of patients. High-quality clinical trials and meta-analyses have emphasized nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of HES solutions. Scientific evidence was derived from international guidelines, aggregated research literature, and opinion-based evidence was obtained from surveys and other activities (e.g., internet postings). On critical analysis of the current data available, it can be summarized that further large scale trials are still indicated before HES can be discarded.
Collapse
Affiliation(s)
- Rashmi Datta
- Department of Anaesthesiology & Critical Care, Army Hospital (R & R), Delhi Cantonment, India
| | - Rajeev Nair
- Department of Anaesthesiology & Critical Care, Army Hospital (R & R), Delhi Cantonment, India
| | - Anil Pandey
- Department of Anaesthesiology & Critical Care, Army Hospital (R & R), Delhi Cantonment, India
| | - Nitish Kumar
- Department of Anaesthesiology & Critical Care, Army Hospital (R & R), Delhi Cantonment, India
| | - Tapan Sahoo
- Department of Anaesthesiology & Critical Care, Army Hospital (R & R), Delhi Cantonment, India
| |
Collapse
|
7
|
Priebe HJ. Methodological issues of the studies cited. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:735. [PMID: 24222798 PMCID: PMC3822715 DOI: 10.3238/arztebl.2013.0735a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
|
8
|
Schorr M. Studies are carried out in hospitals. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:735. [PMID: 24222799 PMCID: PMC3822716 DOI: 10.3238/arztebl.2013.0735b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
|
9
|
Reinhart K. In reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:735-736. [PMID: 24222800 PMCID: PMC3822717 DOI: 10.3238/arztebl.2013.0735c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Konrad Reinhart
- *Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena,
| |
Collapse
|
10
|
Koch T. Rethinking the role of hydroxyethyl starch in fluid replacement. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:441-442. [PMID: 23885278 PMCID: PMC3719449 DOI: 10.3238/arztebl.2013.0441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Thea Koch
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden
| |
Collapse
|