Clinical impact of disinvestment in hydroxyethyl starch for patients undergoing coronary artery bypass surgery: a retrospective observational study

Abstract

Purpose To examine the effect of discontinuing hydroxyethyl starch (HES) solutions on length of hospital stay, transfusion, risk of death, acute kidney injury (AKI), and dialysis. Methods We conducted a historical cohort study of linked administrative and clinical databases in patients undergoing coronary artery bypass surgery (CABG) on cardiopulmonary bypass. We used propensity scores to match patients who did not receive HES (after discontinuation) with patients exposed to HES (before discontinuation) and also controlled for albumin exposure. Hospital length of stay (the primary outcome) was analyzed using Fine-Gray proportional hazard regression, with hospital discharge as the outcome and death as a competing risk. Adverse outcomes were compared between matched patients using conditional logistic regression.Results We compared 1,085 propensity score-matched pairs (n = 2,170) from a pool of 2,757 patients.

Hydroxyl Ethyl Starch (HES) Preserves Intrarenal Microcirculatory Perfusion Shown by Contrast-Enhanced Ultrasound (Ceus), and Renal Function in a Severe Hemodilution Model in Pigs

“…Recently, it has been reported that using 30 mL/kg of 6% hydroxyethyl starches (HES) 130/0.4, but not lower doses, for cardiopulmonary bypass and intraoperative fluid therapy may be associated with a greater risk of AKI (4,5). However, the discontinuation of HES only reduced hospital length of stay but not hospital mortality rate or requirement for dialysis in a retrospective analysis of 2,170 patients with bypass surgery (6). On the other hand a recent propensity matched clinical study in surgical patients it has been shown that % 6 HES 130/0.4 was not associated with the severity and incidence of AKI and resulted in a reduction in the need for renal replacement therapy (RRT) (7).…”

Re-framing the question: Should hydroxyethyl starch be used in clinical practice?

“…Two studies published in this issue of the Journal show how HES use changed following the Health Canada warning, and what the clinical impact of HES de-investment was in cardiac surgery. 12,13 Using hospital purchasing and supply data at an academic centre (The Ottawa Hospital, Ontario, Canada), Pysyk et al showed that, in the six months following the Health Canada HES warning, ordering of HES to the operating rooms decreased by 81% compared with baseline. 12 Removal of HES from the anesthesia drug cart further reduced HES use to \ 1% of pre-Health Canada warning levels.…”

“…Building on the previous study, Hong et al, at a second academic centre (London Health Sciences Centre, Ontario, Canada), conducted a retrospective propensity-matched cohort study evaluating the impact of HES withdrawal in patients undergoing coronary artery bypass surgery with cardiopulmonary bypass (CPB). 13 The methods used to conduct this study were excellent; the authors took great care to control for known confounders and to account for secular time-trends and albumin exposure. In 2,170 matched patients, the withdrawal of HES was associated with shorter duration of hospital stay and reduced transfusion of red cells, plasma, and platelets, but did not significantly impact hospital mortality or use of dialysis.…”

“…Deux études publiées dans ce numéro du Journal montrent que l'utilisation du HEA a changé après la mise en garde de Santé Canada et quel a été l'impact clinique du désinvestissement dans le HEA en chirurgie cardiaque. 12,13 En utilisant des données sur les achats et l'approvisionnement d'un hôpital universitaire (l'hôpital d'Ottawa, Ontario, Canada), Pysyk et coll. ont montré de façon convaincante que dans les six mois suivant la mise en garde de Santé Canada sur le HEA, ses commandes pour les salles d'opération ont diminué de 81 %.…”

“…ont mené dans un autre centre universitaire (Centre des sciences de la santé de London, Canada, Ontario) une étude de cohorte rétrospective appariée par propension afin d'évaluer les répercussions du retrait du HEA chez les patients subissant un pontage aortocoronarien avec circulation extracorporelle (CEC). 13 Les méthodes utilisées pour mener cette étude étaient excellentes; les auteurs ont pris grand soin de contrôler les facteurs confondants connus et de prendre en compte les tendances à long terme et l'exposition à l'albumine. Chez 2 170 patients appariés, le retrait du HEA a été associé à une durée de séjour à l'hôpital plus courte et à une diminution des transfusions de globules rouges, plasma et plaquettes, mais n'a pas abaissé de façon significative la mortalité hospitalière ou le recours à la dialyse.…”