Comparison of the Effects of Albumin 5%, Hydroxyethyl Starch 130/0.4 6%, and Ringer’s Lactate on Blood Loss and Coagulation After Cardiac Surgery

Abstract

T he optimal perioperative fluid management regimen for patients having major surgery is still being debated. Crystalloids (eg, Ringer's lactate [RL]), and colloids such as hydroxyethyl starch (HES) and 5% human serum albumin (HA) are used for intraoperative fluid management in patients undergoing cardiac surgery. The latter 2 expand circulating volume to a greater extent than crystalloids and could be used for a restrictive fluid therapy regimen. Human serum albumin and HES, however, can affect blood coagulation and contribute to increased transfusion requirements. This randomized, double-blind, single-center study was performed over 4 years to compare external blood loss from chest drains among groups receiving 5% HA, 6% HES 130/0.4, or RL as the main infusion during cardiac surgery.Eighty patients each were randomized to receive 50 mL/kg per day of either HA, HES, or RL 50 mL/kg per day, with additional RL given as required. Fluid administration was started with 250 to 500 mL of the study solution during anesthesia induction. Intraoperative fluid therapy with the study solution was restricted to two-thirds of the maximally allowed daily dose (33.3 mL/kg). The last 16.7 mL/kg was kept for initial volume replacement in the intensive care unit (ICU). Rotation thromboelastometry ex vivo coagulation variables were examined. The primary outcome was clinical bleeding based on chest tube drainage during the first 24 hours. Blood transfusion, thromboelastometry variables, perioperative fluid balance, renal function, mortality, and ICU and hospital stays were also evaluated.The final cohort included 76, 81, and 79 patients in the HA, HES, and RL groups, respectively. Median chest tube drainage over 24 hours postoperatively did not differ among the groups (HA, 835 mL; HES, 700 mL; RL, 670 mL; P = 0.0850). The groups differed, however, in the quantity of blood transfusion (packed red blood cells [PRBCs] for HA and HES 300 mL, 0 for RL; P < 0.0004). Most units of PRBCs were given perioperatively during the first 24 hours. No intergroup differences were apparent for transfused FFP and platelets. Fibrinogen was required in 12%, 16%, and 4% of patients in the HA, HES, and RL groups, respectively (P = 0.0383). No differences were found in the 3 groups for the amount of coagulation factor concentrates given. Packed red blood cells were given to 58%, 61%, and 24% of patients in the HA, HES, and RL groups, respectively (P = 0.0013) and any blood product to 62%, 64%, and 35%, respectively (P = 0.0003). During surgery, hemoglobin (Hb) values declined from baseline in all groups, but those in the RL group showed the least decline during surgery and at arrival in the ICU (P < 0.0001 for both). At 24 hours postoperatively, HA patients had the lowest Hb values compared with HES and RL groups (P < 0.0001 for both). The Hb values did not differ among the 3 groups on postoperative day (POD) 6. Maximal clot firmness decreased in all groups during surgery but stayed in the reference range in the HA and RL groups; the lowest value was seen ...

Effect of fluid resuscitation with balanced solutions on platelets: In vitro simulation of 20% volume substitution

“…of number of platelets) remained within reference laboratory values. These results are in line with previous investigations showing that crystalloids have less effect on blood coagulation compared to colloids [10]. Contrary to a few other studies, we revealed that platelet function was not affected by the study solutions.…”

Cohort Study of Albumin versus Lactated Ringer's for Postoperative Cardiac Surgery Fluid Resuscitation in the Intensive Care Unit

“…In addition, more patients returned to the OR for bleeding during the period when albumin was used more often. These findings may suggest that the bleeding risk may be less when albumin is avoided, as albumin has been shown to negatively affect the coagulation cascade and lead to more bleeding in cardiac surgery patients …”

The effect of tranexamic acid on blood coagulation in total hip replacement arthroplasty: rotational thromboelastographic (ROTEM®) analysis

“…There has recently been concern regarding the use of HES infusions in surgical patients, and HES has been universally accepted to be contra-indicated in patients with sepsis, burn injuries or critical illness [31]. In addition, HES is known to interfere with blood coagulation [32,33]. However, it has been reported that surgical patients did not suffer adverse renal effects, increased blood loss, more transfusion, or increased mortality in response to intra-operative HES administration [34].…”