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Wang T, Wang J, Zhang M, Zhang H, Zhang Q, Liu G, Dong W, Wang Y, Ji B. Effects of albumin and crystalloid priming strategies on red blood cell transfusions in on-pump cardiac surgery: a network meta-analysis. BMC Anesthesiol 2024; 24:26. [PMID: 38229019 DOI: 10.1186/s12871-024-02414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/11/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND In on-pump cardiac surgery, the albumin priming strategy could maintain colloid osmotic pressure better than crystalloid solutions and reduce excessive perioperative fluid balance. However, a high-quality meta-analysis is required to compare the safety of these approaches in perioperative red blood cell (RBC) transfusions. Owing to limited direct evidence, we conducted a network meta-analysis (NMA) to increase the pool of studies and provide indirect evidence. METHODS The pre-defined primary outcomes were intraoperative and the first 24 h postoperative RBC transfusion volume in units. The pre-defined secondary outcome was postoperative blood loss (the first 24 h). We reviewed all randomized controlled trials comparing albumin, crystalloid, and artificial colloid priming strategies. Studies that only displayed pre-defined outcomes could be included. A pairwise meta-analysis was performed on studies that directly compared the pre-defined outcomes between albumin and crystalloids. Additionally, a random-effects network meta-analysis (NMA) model was employed to generate indirect evidence for the pre-defined outcomes between albumin and crystalloids. RESULTS The literature search identified 830 studies,10 of which were included in the final analysis. Direct meta-analysis indicated that crystalloid priming significantly decreased total perioperative RBC transfusions (MD: -0.68U; 95%CI: -1.26, -0.09U; P = 0.02) and intraoperative RBC transfusions (MD: -0.20U; 95%CI: -0.39, -0.01U; P = 0.03) compared to albumin. Postoperative RBC transfusions showed a decreasing trend in the crystalloid group; however, the difference was not statistically significant. (MD: -0.16U; 95%CI: -0.45, 0.14U; P = 0.30). After including indirect evidence, the NMA results continued to demonstrate a higher RBC receiving with the albumin priming strategy compared to crystalloids, although the differences did not reach statistical significance. For postoperative blood loss, direct evidence showed no significant differences between albumin and crystalloid priming strategies. However, NMA evidence displayed that albumin exist higher probability of reducing postoperative blood loss than crystalloid. CONCLUSION Both direct and NMA evidence indicated that the albumin priming strategy resulted in more perioperative RBC transfusions than crystalloids. Considering the additional blood management burden, the application of an albumin-priming strategy in on-pump cardiac surgery still needs more consideration.
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Affiliation(s)
- Tianlong Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 10010, China
| | - Jing Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 10010, China
| | - Mingru Zhang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Han Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 10010, China
| | - Qiaoni Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 10010, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 10010, China
| | - Wenhao Dong
- Surgical Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yuefu Wang
- Surgical Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 10010, China.
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Beukers AM, de Ruijter JAC, Loer SA, Vonk A, Bulte CSE. Effects of crystalloid and colloid priming strategies for cardiopulmonary bypass on colloid oncotic pressure and haemostasis: a meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6581082. [PMID: 35512381 PMCID: PMC9419694 DOI: 10.1093/icvts/ivac127] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anne Maria Beukers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | | | - Stephan Alexander Loer
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | - Alexander Vonk
- Amsterdam UMC Location University of Amsterdam, Department of Cardiothoracic Surgery , Amsterdam, Netherlands
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Wei L, Li D, Sun L. The comparison of albumin and 6% hydroxyethyl starches (130/0.4) in cardiac surgery: a meta-analysis of randomized controlled clinical trials. BMC Surg 2021; 21:342. [PMID: 34511097 PMCID: PMC8436511 DOI: 10.1186/s12893-021-01340-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 08/28/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ling Wei
- Department of Rehabilitation, The Second Xiangya Hospital, Central South University, Changsha, 410011, China.,Hunan Key Laboratory of Kidney Disease and Blood Purification, Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Dongping Li
- Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lin Sun
- Hunan Key Laboratory of Kidney Disease and Blood Purification, Department of Nephrology, Second Xiangya Hospital, Central South University, Changsha, 410011, China.
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Güneş I, Süngü N, Kılıçarslan A, Şıvgın V, Alkan M, Küçük A, Boyunağa H, Ünal Y, Arslan M. Effects of hydroxyethyl starch 130/0.4 on the kidney tissue of rats with ureteral obstruction. Drug Des Devel Ther 2018; 12:3061-3070. [PMID: 30275683 PMCID: PMC6157580 DOI: 10.2147/dddt.s165695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective This study was conducted since the effects of colloid solutions on the renal system remain controversial and need to be adequately studied in animals. We aimed to evaluate the effects of hydroxyethyl starch (Voluven) on the kidney tissue of rats with late renal failure due to ureteral obstruction. Materials and methods Rats were divided into four groups: Group C, control; Group HES, hydroxyethyl starch solution (HES) 130/0.4 (Voluven®); Group UUO, unilateral ureteral obstruction (UUO); and Group UUO-HES, UUO-HES 130/0.4 (Voluven®). In the groups with ureteral obstruction, the distal part of the right ureter was accessed and sutured through a lower abdominal incision under ketamine anesthesia. Any signs of late-stage renal failure were evaluated after three weeks. Rats in the HES group and the renal failure-HES group were administered with HES 130/0.4 as a single intravenous dose of 20 mL/kg. After a follow-up of 24 hours, intra-abdominal blood sample was collected, and the rats were sacrificed. Biochemical and histopathological parameters were then evaluated. Results Ureteral obstruction significantly increased urea and creatinine levels. In addition, when the UUO-HES and HES groups were compared, the administration of HES increased urea and creatinine levels in the UUO-HES group. Nitric oxide enzyme activity and malondialdehyde levels have significantly increased in the UUO groups. In addition, HES significantly increased nitric oxide activity and malondialdehyde levels in the UUO-HES group, in comparison with the HES group. The activity of caspases 3 and 8 was significantly increased in the UUO groups. In addition, HES significantly increased the activity of caspases 3 and 8 in the UUO-HES group, in comparison with the HES group. Light microscopy revealed significant changes in the UUO groups, especially in the obstructed kidneys. Conclusion If indicated, HES should be used with caution in cases of UUO, but not in the cases of bilateral ureteral obstruction. Other aspects of these findings, including the clinical significance and practical applications, merit further experimental and clinical investigation.
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Affiliation(s)
- Işın Güneş
- Department of Anaesthesiology and Reanimation, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Nuran Süngü
- Department of Pathology, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Aydan Kılıçarslan
- Department of Pathology, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Volkan Şıvgın
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
| | - Metin Alkan
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
| | - Ayşegül Küçük
- Department of Physiology, Dumlupınar University Medical Faculty, Kütahya, Turkey
| | - Hakan Boyunağa
- Department of Biochemistry, Kırıkkale University Medical Faculty, Kırıkkale, Turkey
| | - Yusuf Ünal
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
| | - Mustafa Arslan
- Department of Anaesthesiology and Reanimation, Gazi University Medical Faculty, Ankara, Turkey,
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Krabbe J, Ruske N, Braunschweig T, Kintsler S, Spillner JW, Schröder T, Kalverkamp S, Kanzler S, Rieg AD, Uhlig S, Martin C. The effects of hydroxyethyl starch and gelatine on pulmonary cytokine production and oedema formation. Sci Rep 2018; 8:5123. [PMID: 29572534 PMCID: PMC5865122 DOI: 10.1038/s41598-018-23513-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 03/15/2018] [Indexed: 01/27/2023] Open
Abstract
Recently, side effects of plasma expanders like hydroxyethyl starch and gelatine gained considerable attention. Most studies have focused on the kidneys; lungs remain unconsidered. Isolated mouse lungs were perfused for 4 hours with buffer solutions based on hydroxyethyl starch (HES) 130/0.4, HES 200/0.5 or gelatine and ventilated with low or high pressure under physiological pH and alkalosis. Outcome parameters were cytokine levels and the wet-to-dry ratio. For cytokine release, murine and human PCLS were incubated in three different buffers and time points.In lungs perfused with the gelatine based buffer IL-6, MIP-2 and KC increased when ventilated with high pressure. Wet-to-dry ratios increased stronger in lungs perfused with gelatine - compared to HES 130/0.4. Alkalotic perfusion resulted in higher cytokine levels but normal wet-to-dry ratio. Murine PCLS supernatants showed increased IL-6 and KC when incubated in gelatine based buffer, whereas in human PCLS IL-8 was elevated. In murine IPL HES 130/0.4 has lung protective effects in comparison to gelatine based infusion solutions, especially in the presence of high-pressure ventilation. Gelatine perfusion resulted in increased cytokine production. Our findings suggest that gelatine based solutions may have side effects in patients with lung injury or lung oedema.
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Affiliation(s)
- Julia Krabbe
- Institute of Pharmacology and Toxicology, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Intensive Care and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Nadine Ruske
- Institute of Pharmacology and Toxicology, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
| | - Till Braunschweig
- Institute of Pathology, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Svetlana Kintsler
- Institute of Pathology, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jan W Spillner
- Departement of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Thomas Schröder
- Department of Surgery, Luisenhospital Aachen, Boxgraben 99, 52064, Aachen, Germany
| | - Sebastian Kalverkamp
- Departement of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Stephanie Kanzler
- Institute of Pharmacology and Toxicology, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
| | - Annette D Rieg
- Institute of Pharmacology and Toxicology, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Stefan Uhlig
- Institute of Pharmacology and Toxicology, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
| | - Christian Martin
- Institute of Pharmacology and Toxicology, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
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Choice of fluid type: physiological concepts and perioperative indications. Br J Anaesth 2018; 120:384-396. [DOI: 10.1016/j.bja.2017.10.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
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Sacchet-Cardozo F, Stoicea N, Joseph N, Dewhirst E, Essandoh M. Con: Hetastarch Should be Avoided for Volume Expansion in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2018; 32:576-579. [DOI: 10.1053/j.jvca.2016.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Indexed: 11/11/2022]
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Mechanical blood trauma in assisted circulation: sublethal RBC damage preceding hemolysis. Int J Artif Organs 2016; 39:150-9. [PMID: 27034320 DOI: 10.5301/ijao.5000478] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2016] [Indexed: 02/06/2023]
Abstract
After many decades of improvements in mechanical circulatory assist devices (CADs), blood damage remains a serious problem during support contributing to variety of adverse events, and consequently affecting patient survival and quality of life. The mechanisms of cumulative cell damage in continuous-flow blood pumps are still not fully understood despite numerous in vitro, in vivo, and in silico studies of blood trauma. Previous investigations have almost exclusively focused on lethal blood damage, namely hemolysis, which is typically negligible during normal operation of current generation CADs. The measurement of plasma free hemoglobin (plfHb) concentration to characterize hemolysis is straightforward, however sublethal trauma is more difficult to detect and quantify since no simple direct test exists. Similarly, while multiple studies have focused on thrombosis within blood pumps and accessories, sublethal blood trauma and its sequelae have yet to be adequately documented or characterized. This review summarizes the current understanding of sublethal trauma to red blood cells (RBCs) produced by exposure of blood to flow parameters and conditions similar to those within CADs. It also suggests potential strategies to reduce and/or prevent RBC sublethal damage in a clinically-relevant context, and encourages new research into this relatively uncharted territory.
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Abstract
PURPOSE OF REVIEW Infusion therapy is essential in intravascular hypovolaemia and extravascular fluid deficits. Crystalloidal fluids and colloidal volume replacement affect blood coagulation when infused intravenously. The question remains if this side-effect of infusion therapy is clinically relevant in patients with and without bleeding manifestations, and if fluid-induced coagulopathy is a risk factor for anaemia, blood transfusion, and mortality, and a driver for resource use and costs. RECENT FINDINGS Pathomechanisms of dilutional coagulopathy and evidence for its clinical relevance in perioperative and critically ill patients are reviewed. Furthermore, the article discusses medicolegal aspects. SUMMARY The dose-dependent risk of dilutional coagulopathy differs between colloids (dextran > hetastarch > pentastarch > tetrastarch, gelatins > albumin). Risk awareness includes monitoring for early signs of side-effects. With rotational thromboelastometry/thrombelastography, the deterioration not only in clot strength but also in clot formation and in platelet interaction can be assessed. Fibrinogen concentrate administration may be considered in severe bleeding as well as relevant dilutional coagulopathy. Targeted doses of gelatins and tetrastarches seem to have no proven adverse effect on anaemia and allogeneic blood transfusions. Further studies are needed.
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