6%羟乙基淀粉130/0.4对心脏瓣膜置换术患者黏附分子表达的影响

目的观察体外循环（CPB）中使用6％羟乙基淀粉130／0．4（6％HES130／0．4）对心脏瓣膜置换术患者细胞间黏附分子-1（ICAM-1）、血管细胞黏附分子-1（VCAM-1）及血小板内皮细胞黏附分子-1（PECAM-1）表达的影响。方法选择心脏二尖瓣瓣膜置换术患者60例,ASAⅡ或Ⅲ级,随机分为2组,每组30例。6％HES130／0．4组（Ⅴ组）：人工心肺机中预充6％HES130／0．415ml／kg和琥珀酰明胶（Succinyhted Gelatin）对照组（C组）：人工心肺机中预充Succinyhted Gelatin 15ml／kg,两组分别于气管插管后至CPB开始前静脉输注6％HES130／0．4和Succinyhted Gehtin 10ml／kg。麻醉诱导后即刻（T0）、CPB主动脉阻断开放时（T1）、CPB结束时（T2）和手术结束时（T3）分别抽取外周动脉血,分离血清。检测血清中游离黏附分子（sAM）：sICAM-1、sVCAM-1及sPECAM-1）的含量。结果与C组比较,Ⅴ组T0、T1时血清sICAM-1、sVCAM-1及sPECAM-1的含量差异无统计学意义（P〉0．05）;T2、T3时血清sICAM-1、sVCAM-1、sPECAM-1的含量明显减少（P〈0．05）。结论CPB中应用6％HES130／0．4可明显抑制外周血AM的表达,从而减轻CPB触发的炎性反应。     

6％羟乙基淀粉130／0．4在小儿腹部手术中容量治疗的临床应用

目的 探讨6％羟乙基淀粉130／0．4在小儿腹部手术中容量治疗的应用效果。方法60例拟行腹部手术的患儿随机分为观察组和对照组,每组各30例。观察组术中容量治疗使用6％羟乙基淀粉130／0．4及晶体液;对照组未使用6％HES130／0．4,所使用的晶体液与观察组相同,可选用胶体液为浓缩红细胞。观察两组患儿手术前后心率、血压．总输液量及晶体液、胶体液、浓缩红细胞输入量等。记录观察组因输注6％羟乙基淀粉可能出现的不良反应,如：过敏（包括低血压、皮疹等）。结果两组输液总量无显著性差异。观察组与对照组相比：胶体液用量、晶体液用量、浓缩红细胞用量均有显著性差异,（P〈0．05）。观察组未发现因输注6％羟乙基淀粉130／0．4而出现的不良反应。结论6％羟乙基淀粉130／0．4可安全、有效的用于小儿腹部大手术中的容量治疗。     

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

We have evaluated the effect of a colloid solution on acute kidney injury in paediatric cardiac surgery. A total of 195 patients were ramdomly divided into an hydroxyethyl starch group and a control group. In the starch group, 6% hydroxyethyl starch 130/0.4 (Volulyte^®) was used as the primary fluid for volume resuscitation but was limited to 30 ml.kg^?1. In the control group, only crystalloid fluid was used during the peri‐operative period. The incidence of acute kidney injury, peri‐operative transfusion, clinical outcomes and laboratory data were compared. The incidence of acute kidney injury determined by Paediatric Risk, Injury, Failure, Loss, End‐stage renal disease (pRIFLE) and Acute Kidney Injury Network (AKIN) criteria were no different between the two groups (starch group 40.8% vs. control group 30.0%; p = 0.150 using pRIFLE; 19.6% vs. 21.1% respectively, p = 0.602 using AKIN). There were no differences in clinical outcomes such as mortality, major adverse events, intensive care unit stay or duration of mechanical ventilation. Clotting time as measured using rotational thromboelastometry (ROTEM) was prolonged, and clot firmness after 10 min and maximal clot firmness were shorter in the starch group compared with the control group after sternal closure. There was no difference in transfusion between the two groups. Patients with acute kidney injury had worse clinical courses than those without acute kidney injury. We conclude that intra‐operative use of 6% hydroxyethyl starch 130/0.4 up to 30 ml.kg^?1 was not associated with postoperative acute kidney injury in paediatric cardiac patients.     

Coagulation effects of a recently developed hydroxyethyl starch (HES 130/0.4) compared to hydroxyethyl starches with higher molecular weight

BACKGROUND: Hydroxyethyl starches (HES) are known to interfere with blood coagulation according to molecular weight, the degree of substitution and the C2/C6 ratio. A recently developed low molecular hydroxyethyl starch (HES 130/0.4) was designed to reduce the blood compromising potency. METHODS: In this study, effects of a 30% in vitro haemodilution with the new HES preparation (HES 130/0.4) in comparison to HES 200/0.5, HES 450/0.7 and sodium chloride solution were investigated using intrinsic and extrinsic activated thrombelastography (TEG) and plasmatic coagulation tests. RESULTS: Whereas plasmatic tests revealed no prolongation of coagulation by HES in comparison to sodium chloride, the TEG variables clotting time, clot formation time and maximal clot firmness showed a significant (P<0.05) inhibition by all the HES preparations. The inhibition was most pronounced in HES 450 (P<0.05 vs HES 130) while HES 130 did not show a statistically significant difference in extrinsic activated maximal clot firmness when compared to sodium chloride. CONCLUSION: These in vitro results demonstrate that hydroxythyl starches especially compromise clot polymerisation. The new preparation HES 130/0.4 seems to inhibit platelet function to a lesser extent than hydroxyethyl starch preparations with a higher molecular weight and degree of substitution.     

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.     

6%羟乙基淀粉130/0.4体外循环预充对心脏手术患儿血浆胶体渗透压及乳酸水平的影响

Objective To investigate the effects of hydroxyethyl starch 130/0.4 (HES) used as priming fluid for cardiopulmonary bypass (CPB) on the plasma colloid osmotic pressure (COP) and lactic acid (LAC) concentration in infants undergoing cardiac surgery.Methods Forty infants of either sex with age ≤6 yr undergoing cardiac surgery with CPB were randomly divided into 2 groups (n =20 each): HES group and control group. The left radial artery and the right internal jugular vein were cannulated for blood pressure (BP) and the central venous pressure (CVP) monitoring. Arterial blood gases, blood LAC concentration, hemoglobin (Hb), hematocrit (Hct), mean arterial pressure (MAP) and nasopharyngeal temperature were measured and recorded immediately before and 5 min after aortic cross-clamping, at the end of CPB and operation. Plasma COP was measured before induction of anesthesia (T1), at 5 and 30 min of CPB (T2 and T3, respectively), before routine ultra-filtration (T4), at the end of CPB (T5) and2 h in ICU (T6).Results The plasma LAC concentration was significantly lower and the COP significantly higher in HES group than in control group (P＜0.05 or 0.01).The plasma LAC concentration increased after aortic cross-clamping, reached the peak at the end of CPB and then declined at the end of operation, but was still higher than that before aortic cross-clamping in both groups. Plasma COP was significantly decreased during CPB as compared with the baseline at T1, but increased at T6 in both groups.Conclusion Using HES 130/0.4 as pdming fluid for CPB can effectively improve plasma COP and reduce blood LAC level in infants undergoing cardiac surgery with CPB.     

The influence of intravascular volume therapy with a new hydroxyethyl starch preparation (6% HES 130/0.4) on coagulation in patients undergoing major abdominal surgery

A new hydroxyethyl starch (HES) preparation with a mean molecular weight of 130,000 daltons and a degree of substitution of 0.4 shows favorable pharmacokinetic properties. We conducted a study of the influence of the new HES specification on coagulation and compared it with another colloidal intravascular volume replacement regimen using gelatin. According to a prospective, random sequence, 42 patients undergoing major abdominal surgery received either HES 130/0.4 (n = 21) or gelatin (n = 21) until the first postoperative day (POD) to keep central venous pressure between 10 and 14 mm Hg. From arterial blood samples, standard coagulation variables were measured, and modified thrombelastogram (TEG) measurements using different activators were performed. A total of 2830 +/- 350 mL of gelatin and 2430 +/- 310 mL of HES 130/0.4 were administered until the morning of the first POD. The use of allogeneic blood/blood products and standard coagulation variables did not differ significantly between the two groups. After induction of anesthesia, all TEG data for both groups were within normal range. Coagulation time and maximum clot firmness did not change significantly in any TEG measurements during the study period. The kinetics of clot formation (clot formation time) significantly increased immediately after surgery, but without showing significant group differences. On the morning of the first POD, the clot formation time returned to almost normal levels, except for aprotinin-activated TEG(R). We conclude that administration of moderate doses of the new HES 130/0.4 preparation in patients undergoing major abdominal surgery results in similar coagulation alterations as those after using an established gelatin-based volume-replacement regimen. IMPLICATIONS: We compared the effects of infusion of a new hydroxyethyl starch preparation (6% hydroxyethyl starch; mean molecular weight 130,000 daltons; degree of substitution 0.4) on coagulation with a gelatin-based intravascular volume replacement regimen in patients undergoing major abdominal surgery. After moderate doses of hydroxyethyl starch (2430 +/- 310 mL until the morning of the first postoperative day), coagulation monitoring, including modified thrombelastography, did not show impaired hemostasis.     

Hydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in children: preliminary results of a European Prospective Multicenter Observational Postauthorization Safety Study (PASS)

Background: Several clinical studies have shown that hydroxyethyl starch (HES) may be as effective and safe as, but less expensive than, albumin when used for perioperative plasma volume replacement (PVR) in children. The new third generation HES 130/0.42 solution was designed to reduce adverse drug reactions (ADRs) and improve safety while maintaining efficacy. Therefore, the objective of this prospective multicenter observational postauthorization safety study (PASS) was to evaluate the perioperative use of HES 130/0.42 in 1000 children with a particular focus on possible ADRs. Methods: Approximately 300 of 1000 pediatric patients aged up to 12 years with ASA risk scores of I–III receiving perioperative HES 130/0.42 (Venofundin 6%; Braun, Melsungen, Germany) should be enrolled for interims analysis in the first year. The statistical sample size calculation showed that this number of patients would be sufficient to detect a 1% incidence of ADRs. Following approval by local ethics committee, patient demographics, data relating to HES 130/0.42 use, the procedures performed, anesthesia, and ADRs were documented with a particular focus on cardiovascular stability, hemodilution, acid–base balance, renal function, blood coagulation, and hypersensitivity. Results: Three hundred and sixteen children (ASA I–III, age 3 ± 3.4 [range, day of birth–12 years], body weight 13 ± 10.5 [range, 1.1–60 kg]) were studied at five centers in Germany, Austria, and Italy from May 2006 until August 2007. Forty‐five percent of the patients underwent abdominal surgery, 12.4% urologic procedures, 11.4% thoracic surgery, 7.6% orthopedic procedures, and 7% cardiovascular surgery. The mean volume of infused HES 130/0.42 was 11 ± 4.8 ml·kg^?1 (range, 5–42). Cardiovascular stability was maintained in all cases. After HES infusion, hemoglobin (11.5 vs 10.25 g·dl^?1), base excess (?2 vs ?2.7 mmol·l^?1), anion gap (12.9 vs 11.2 mmol·l^?1), and strong ion difference (34.3 vs 31.4 mmol·L^?1) decreased, and chloride (105.7 vs 107.8 mmol·l^?1) increased significantly (P < 0.05). No serious ADRs (i.e., anaphylactoid reaction, renal failure, clotting disorders) were observed. Conclusion: Moderate doses of HES 130/0.42 help to maintain cardiovascular stability and lead to only moderate changes in hemoglobin concentration and acid–base balance in children. The probability of serious ADRs is lower than 1%. Therefore, HES 130/0.42 for PVR seems to be safe and effective even in neonates and small infants with normal renal function and coagulation.     

Volume replacement therapy during major orthopedic surgery using Voluven (hydroxyethyl starch 130/0.4) or hetastarch

BACKGROUND: The purpose of this study was to test the equivalence of efficacy and compare the safety of the 6% hydroxyethyl starches (HES) Voluven (HES 130/0.4; Fresenius Kabi, Bad Homburg, Germany) and hetastarch (HES 670/0.75 in saline) for intravascular volume replacement therapy during major orthopedic surgery. METHODS: In a prospective, controlled, randomized, double-blind, multicenter trial of patients undergoing major orthopedic surgery, 49 patients were treated with HES 130/0.4 and 51 patients were treated with hetastarch. Infusion of colloids was guided by central venous and arterial blood pressures. The primary efficacy endpoint was the volume of colloid solution infused; the primary safety endpoints were calculated total erythrocyte loss, the nadir factor VIII activity, and the nadir von Willebrand factor concentration within 2 h of completion of surgery. RESULTS: The total volume of colloid solution required for intraoperative volume replacement did not differ between HES 130/0.4 and hetastarch (1,613+/-778 [SD] ml for HES 130/0.4 and 1,584+/-958 ml for hetastarch). The nadir factor VIII activity within 2 h of the end of surgery was lower for hetastarch than for HES 130/0.4 (P=0.0499); for those who received greater than 1,000 ml colloid, the nadir factor VIII activity and von Willebrand factor concentration within 2 h of end of surgery were lower for hetastarch than for HES 130/0.4 (P=0.0487 and P=0.008, respectively). CONCLUSION: Voluven (HES 130/0.4) and hetastarch are equally efficacious plasma volume substitutes; however, HES 130/0.4 has a lesser effect on coagulation.     

Alteration of anion gap and strong ion difference caused by hydroxyethyl starch 6% (130/0.42) and gelatin 4% in children

Background: Synthetic colloid administration is a common practice for preventing perioperative hypovolemia and consecutive circulatory failure in children. This prospective, randomized study was conducted to investigate the effects of two different unbalanced synthetic colloid solutions on acid–base equilibrium in children. Methods: Fifty pediatric patients (aged 0–12 years) scheduled for major pediatric surgery were randomized to receive either 10 ml·kg^?1 of 6% hydroxyethyl starch solution 130/0.42 (HES) or 4% modified fluid gelatin (GEL) to maintain adequate systemic hemodynamics. Before and after colloid administration, a blood sample was collected to analyze hemoglobin, hematocrit, electrolytes, and acid–base parameters. The anion gap and the strong ion difference (SID) were calculated using standard formulas. Results: Both HES and GEL administration caused a significant increase in plasma chloride concentration (P < 0.01) and an accompanying decrease in SID (P < 0.01). In the HES group, the anion gap decreased significantly (P < 0.01) whereas the anion gap remained stable in the GEL group. In both groups, initial actual base excess and pH did not change significantly after colloid administration. Conclusions: Moderate intraoperative plasma replacement with unbalanced synthetic colloids HES and GEL leads to a decrease in SID and, in the case of HES, to a significant decrease in the anion gap in children. These alterations may result in a possible misinterpretation when the anion gap and SID are used for differential diagnosis of metabolic disturbances during major pediatric surgery.     

The effects of in vitro hemodilution with 6% hydroxyethyl starch (HES) (130/0.4) solution on thrombelastograph analysis in patients undergoing liver transplantation

Bang SR, Kim YH, Kim GS. The effects of in vitro hemodilution with 6% hydroxyethyl starch (HES) (130/0.4) solution on thrombelastograph analysis in patients undergoing liver transplantation.
Clin Transplant 2011: 25: 450–456. © 2010 John Wiley & Sons A/S. Abstract: Introduction: The aim of this study was to determine the effects of in vitro hemodilution with 6% HES (130/0.4) solution on thrombelastograph^® (TEG) parameters in whole blood samples from patients with end‐stage liver disease (ESLD). Methods: Enrollment consisted of 95 patients with ESLD undergoing liver transplantation. Blood was diluted by 11%, 22%, and 33% with 6% HES (130/0.4) solution. Normal saline was used as a control diluent. Results: When blood was diluted by 33% with normal saline, only the reaction time (r) was increased (p < 0.0001) compared to the baseline value. When blood was diluted with 6% HES (130/0.4), 11% dilution decreased maximum amplitude (MA) (p = 0.003) compared to baseline. At 33% dilution, the r (p < 0.0001, vs. baseline) and K (p < 0.0001, vs. baseline; p < 0.0001, vs. normal saline) increased, and the MA, alpha angle, and coagulation index (p < 0.0001, vs. baseline; p < 0.0001, vs. normal saline) decreased. Conclusion: Hemodilution with 6% HES (130/0.4) solution results in TEG abnormalities even with 11% hemodilution, in whole blood samples of patients with ESLD undergoing liver transplantation.     

Hydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in 1130 children: results of an European prospective multicenter observational postauthorization safety study (PASS)

Introduction: Third‐generation hydroxyethyl starch (HES) is now approved also for the use in children, but safety studies including large numbers of pediatric patients are still missing. Therefore, we performed an European multicentric prospective observational postauthorization safety study (PASS) to evaluate the use of HES 130/0.42/6:1 in normal saline (ns‐HES) or a balanced electrolyte solution (bal‐HES) in children undergoing surgery. Methods: Children aged up to 12 years with ASA risk scores of I–III receiving ns‐HES (Venofundin 6%; Braun) or bal‐HES (Tetraspan 6%; Braun) were followed perioperatively. Demographic data, surgical procedures performed, anesthesia, hemodynamic and laboratory data, adverse events (AE), and adverse drug reactions (ADR) were documented using a standardized case report form. Results: Of 1130 children studied at 11 European pediatric centers from 2006 to 2009 (ns‐HES, 629 children; bal‐HES, 475 children; mean age, 3.6 ± 3.8 [range, day of birth–12 years]; and body weight, 15.4 ± 13 [0.9–90 kg]), 1104 were included for analysis. The mean infused HES volume was 10.6 ± 5.8 (0.83–50) ml·kg^?1. In the 399 (36.1%) cases with blood gas analysis before and after HES infusion, hemoglobin and strong ion difference decreased significantly in both groups, whereas bicarbonate and base excess (BE before infusion: ns‐HES ?1.8 ± 3.1, bal‐HES ?1.2 ± 3.3 mm ; after infusion: ns‐HES ?2.5 ± 2.8; bal‐HES ?1.1 ± 3.2 mm , P < 0.05) decreased only with ns‐HES but remained stable with bal‐HES. Chloride concentrations increased in both groups and were significantly higher with ns‐HES (Cl before infusion: ns‐HES 105.5 ± 3.6, bal‐HES 104.9 ± 2.9 mm ; Cl after infusion: ns‐HES 107.6 ± 3.4, bal‐HES 106.3 ± 2.9 mm , P < 0.05). For the AE/ADR rates, dose–response but no age relationships could be demonstrated. No serious and no severe ADR directly related to HES (i.e. anaphylactoid reaction, clotting disorders, renal failure) were observed. Conclusion: Moderate doses of HES 130/0.42/6:1 for perioperative plasma volume replacement seem to be safe even in neonates and small infants. The probability of serious ADR is lower than 0.3%. Changes in acid–base balance may be decreased when HES is used in an acetate‐containing balanced electrolyte solution instead of normal saline. Caution should be exercised in patients with renal function disturbances and those with an increased bleeding risk.     

Equivalence of hydroxyethyl starch HES 130/0. 4 and HES 200/0. 5 for perioperative volume replacement in major gynaecological surgery

BACKGROUND: Hydroxyethyl starch solutions (HES) are increasingly used for the compensation of surgical blood loss. The objective of this clinical trial was to compare a novel 6% HES 130/0.4 solution with a favourable pharmacological profile and a standard 6% HES 200/0.5 solution for maintenance of haemodynamic stability in major gynaecological surgery. METHODS: Sixty female patients aged 18-80 years undergoing major gynaecological surgery with indication for perioperative colloidal volume replacement were enrolled in this prospective, randomized double-blinded clinical study. The administration of study medication was dependent on individual requirements to maintain haemodynamic stability. The amount of study medication required from induction of anaesthesia until 6 h postoperatively served as the primary investigative parameter. RESULTS: The two one-sided test procedure by Westlake demonstrated equivalence of mean infused volumes between HES 130/0.4 and HES 200/0.5 during the study period (1224 +/- 544 ml and 1389 +/- 610 ml, respectively, P < 0.05). Perioperatively, haemodynamics did not differ significantly between treatment groups. While none of the mean values of coagulation parameters shifted outside the normal range, the degree of haemodilution revealed reduced haematocrit values in HES 200/0.5 treated patients at 6 h postoperatively (P < 0.05). Moreover, prothrombin time (PT) was higher and consequently international normalized ratio (INR) was lower at the same time point for patients who received HES 130/0.4 (P < 0.05). CONCLUSION: This clinical trial demonstrated therapeutic equivalence of this novel low-substituted HES 130/0.4 solution and a standard HES 200/0.5 solution for perioperative volume replacement. Moreover, both HES preparations were equally well-tolerated and safe.     

Effects of two different hydroxyethyl starch solutions (HES200/0.5 vs. HES130/0.4) on the expression of platelet membrane glycoprotein

BACKGROUND: There are various hydroxyethyl starch (HES) solutions with different degrees of hydroxylation and different molecular weights. HES200/0.5 solution is most commonly used. HES130/0.4 is a new HES solution and is the 'state-of-the-art' in volume substitution. However, the mechanism of the observed anticoagulation action of HES has not been fully delineated. The objective of this study was to further investigate the effect of HES200/0.5 and HES130/0.4 on platelet coagulation. METHODS: Sixty ASA I-II patients undergoing elective minor surgery were randomly allocated to receive an intravenous infusion (20 ml/kg) of lactated Ringer's solution (group L), HES200/0.5 (group H) or HES130/0.4 (group V) after the induction of anesthesia. The expression of CD42b, CD41/61 and CD62p in vivo was assessed on non-stimulated platelets and adenosine diphosphate (ADP) agonist-activated platelets using flow cytometry. RESULTS: Resting glycoprotein expression of the non-stimulated platelets was observed. HES200/0.5 and HES130/0.4 reduced the CD42b, CD41/61 and CD62p expression of ADP-agonist-activated platelets at 15 min after intravenous infusion. At 6 h after intravenous infusion, the trend of decreasing expression of activated CD42b, CD41/61 and CD62p was maintained in group H. However, CD42b, CD41/61 and CD62p expression returned to the pre-operative level in group V. CONCLUSION: This study showed that both HES200/0.5 and HES130/0.4 can inhibit platelet coagulation. Platelet dysfunction experienced a faster recovery after the infusion of HES130/0.4 than after HES200/0.5. Liquid resuscitation with HES130/0.4 may decrease the risk of hemorrhage in the operative period.     

羟乙基淀粉130/0.4急性高容量血液稀释对骨科手术患者内环境的影响

目的探讨硬膜外复合全身麻醉下6%羟乙基淀粉130/0.4急性高容量血液稀释对骨科手术患者内环境的影响。方法选择ASAⅠ或Ⅱ级择期骨科手术患者28例,随机均分为急性高容量血液稀释组(AHH组)和对照组(C组)。均采用硬膜外阻滞复合全身麻醉。AHH组硬膜外阻滞起效后开始血液稀释,快速输入6%羟乙基淀粉130/0.420ml/kg,速率50ml/min;C组常规输液。术中连续监测MAP、HR、SpO2、CVP、ECG和PETCO2。分别于稀释前即刻(T0)、稀释后5min(T1)、120min(T2)采取桡动脉血进行电解质、乳酸(Lac)、血糖(BG)、尿素氮(BUN)、Hct及Hb测定,计算血浆渗透浓度(Posm)。结果AHH组Hct及Hb血液稀释后下降约20%。与C组相比,AHH组患者的MAP、HR较平稳,术中输液量、尿量增多。与T0相比,AHH组T1时CVP升高,T2时pH值降低(P<0.05)。两组患者的BG在T2时增高,且C组高于AHH组(P<0.05)。两组各时点血电解质、Lac、BUN、HCO3-、BE、Posm等各指标差异均无统计学意义。结论硬膜外复合全身麻醉下6%羟乙基淀粉130/0.4急性高容量血液稀释能维持内环境的相对稳定。     

Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for volume expansion in cardiac surgery patients: the effects on perioperative bleeding and transfusion needs

In this prospective, randomized, open controlled study we compared the effects on net red blood cell loss of 6% hydroxyethyl starch 130/0.4 (HES: n = 64) and 3% modified fluid gelatin (GEL: n = 68) administered for intravascular volume management in patients undergoing coronary surgery. Blood losses were calculated from determination of circulating blood volume and measurement of preoperative and postoperative hematocrit. Amount of colloids that could be administered was limited to 50 mL/kg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Both groups were similar with regard to demographic and intraoperative variables. Total study drug was 48.9 +/- 17.2 mL/kg in the HES group and 48.9 +/- 14.6 mL/kg in the GEL group. Total red blood cell loss was 544 +/- 305 mL in the HES group and 504 +/- 327 mL the GEL group. Measured blood losses were also similar in both groups (HES, 19.4 +/- 12.3 mL/kg; GEL, 19.2 +/- 14.5 mL/kg). Exposure to allogeneic blood product was comparable in both groups. In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery.     

Changes in acid-base, electrolyte and hemoglobin concentrations during infusion of hydroxyethyl starch 130/0.42/6 : 1 in normal saline or in balanced electrolyte solution in children

Introduction: A balanced volume replacement strategy is a well established concept for correcting hypovolemia using plasma adapted isotonic crystalloid solutions with a physiological electrolyte pattern and acetate as bicarbonate precursor. Recently, third‐generation hydroxyethyl starch (HES) has also become available in a balanced electrolyte solution instead of normal saline. Therefore, in this prospective non‐interventional clinical study, the perioperative administration of HES 130/0.42/6 : 1 in normal saline (ns‐HES) and in balanced electrolyte solution (bal‐HES) was evaluated in children with a focus on acid‐base, electrolyte and hemoglobin changes. Methods: Following local ethics committee approval, pediatric patients aged up to 12 years with an ASA risk score of I–III undergoing perioperative administration of HES (ns‐HES from May 2006 to December 2007, bal‐HES from January 2008 to January 2009) were included. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data and the results of blood gas analysis were documented with a focus on changes in acid‐base, electrolyte and hemoglobin concentrations. Results: Of 396 enrolled patients (ASA I–III; age 2.3 ± 3, range day of birth – 12 years; body weight 10.8 ± 9, range 0.9–52 kg), 249 received ns‐HES and 147 bal‐HES (mean volume infused 9.9 ± 4 and 9.4 ± 6.9 ml·kg^?1, respectively). After HES infusion, hemoglobin decreased in both groups, whereas bicarbonate and base excess (BE) decreased only with ns‐HES and remained stable with bal‐HES (BE before infusion: ns‐HES ?1.8 ± 2.8, bal‐HES ?1.7 ± 2.7 mmol·l^?1; after infusion: ns‐HES ?2.6 ± 2.4; bal‐HES ?1.6 ± 2.6 mmol·l^?1, P < 0.05). Chloride (Cl) concentrations increased in both groups and were significantly higher with ns‐HES (Cl before infusion: ns‐HES 105.6 ± 3.7, bal‐HES 105.1 ± 2.8 mmol·l^?1; after infusion: ns‐HES 107.7 ± 3.2, bal‐HES 106.3 ± 2.9 mmol·l^?1, P < 0.01). No serious adverse drug reactions were observed. Conclusion: Infusion related iatrogenic acid‐base and electrolyte alterations can be minimized by using hydroxyethyl starch in a balanced electrolyte solution instead of normal saline.     

Microvascular reactivity and endothelial glycocalyx degradation when administering hydroxyethyl starch or crystalloid during off‐pump coronary artery bypass graft surgery: a randomised trial

The infusion of fluids to patients may affect tissue microcirculation and the endothelial glycocalyx. However, the effects of hydroxyethyl starch and crystalloid on endothelial glycocalyx degradation and microvascular reactivity have not been evaluated in detail. We hypothesised that hydroxyethyl starch may cause less endothelial glycocalyx degradation and better microvascular reactivity than that caused by crystalloid. We randomly allocated 120 patients undergoing off‐pump coronary artery bypass graft surgery to receive up to 20 ml.kg^?1 of either hydroxyethyl starch 670/0.75 or crystalloid for intra‐operative fluid resuscitation. Crystalloid was then infused to meet ongoing fluid requirements. During the peri‐operative period, vascular occlusion tests were performed to assess microvascular reactivity, and serum syndecan‐1 was measured as an index of endothelial glycocalyx degradation. The median (IQR [range]) fluid infused during surgery was significantly less in the hydroxyethyl starch group than the crystalloid group; 2800 (2150–3550 [1400–7300]) vs. 3925 (3100–4725 [1900–6700]) ml, respectively, p < 0.001. Vascular occlusion test parameters, including tissue oxygen saturation, occlusion and recovery slope did not differ significantly between the groups. Peri‐operative changes in syndecan‐1 were not significantly different between the groups. We conclude that, in patients undergoing off‐pump coronary artery bypass graft surgery, compared with crystalloid, the use of hydroxyethyl starch 670/0.75 did not result in significant differences in microvascular reactivity or endothelial glycocalyx degradation.