Hydroxyethyl starch for volume expansion after subarachnoid haemorrhage and renal function: Results of a retrospective analysis

Abstract

BackgroundHydroxyethyl starch (HES) was part of “triple-H” therapy for prophylaxis and therapy of vasospasm in patients with subarachnoid haemorrhage (SAH). The European Medicines Agency restricted the use of HES in 2013 due to an increase of renal failure in critically ill patients receiving HES compared to crystalloid fluids. The occurrence of renal insufficiency in patients with SAH due to HES is still uncertain. The purpose of our study was to evaluate whether there was an association with renal impairment in patients receiving HES after subarachnoid haemorrhage.MethodsMedical records of all non-traumatic SAH patients treated at the Departments of Anaesthesiology and Neurosurgery, University Hospital of Leipzig, Germany, between January 2009 and December 2014 were analysed. Patients received either HES 6% and/or 10% (HES group, n = 183) or exclusively crystalloids for fluid therapy (Crystalloid group, n = 93). Primary outcome was the incidence of acute kidney injury.ResultsThe study groups had similar characteristics except for initial SAPS scores, incidence of vasospasm and ICU length of stay. Patients receiving HES fulfilled significantly more often SIRS (systemic inflammatory response syndrome) criteria. 24.6% (45/183) of the patients in the HES group had acute kidney injury (KDIGO 1–3) at any time during their ICU stay compared to 26.9% (25/93) in the crystalloid group (p = 0.679). Only few patients needed renal replacement therapy with no significant difference between groups (Crystalloid group: 4.3%; HES group: 2.2%; p = 0.322). The incidence of vasospasm was increased in the HES group when compared to the crystalloid group (33.9% vs. 17.2%; p = 0.004).ConclusionIn the presented series of patients with non-traumatic SAH we found no significant association between HES therapy and the incidence of acute kidney injury. Treatment without HES did not worsen patient outcome.

Economic and Humanistic Burden of Cerebral Vasospasm and Its Related Complications after Aneurysmal Subarachnoid Hemorrhage: A Systematic Literature Review

“…Forty studies were conducted in single countries: 20 studies in the USA [ 11 , 26 , 30 , 36 , 39 , 41 – 44 , 46 – 48 , 52 , 56 , 58 – 60 , 63 – 65 ], and the remainder in Australia [ 49 ], Brazil [ 29 ], Canada [ 35 ], China [ 31 ], Estonia [ 24 ], Finland [ 50 ], Germany [ 40 , 53 , 54 ], India [ 28 ], Japan [ 33 ], New Zealand [ 51 ], Poland [ 61 ], Portugal [ 57 ], Turkey [ 37 , 38 ], and the UK [ 32 , 45 , 55 , 62 ]. Two RCTs were conducted in multiple countries: the CONSCIOUS-1 trial [ 27 ] in Austria, Canada, Finland, France, Germany, Israel, Italy, Sweden, Switzerland, the UK, and the USA, and another trial [ 34 ] in Canada, the Netherlands, and the USA.…”

“…The longest study was a retrospective cohort analysis of cost drivers for aneurysms using the US Value Driven Outcomes database, which reported data from a 15.5-year period (July 2001 to January 2017) [ 63 ]. Two RCTs [ 30 , 31 ] and 13 observational studies [ 35 – 38 , 40 – 42 , 45 , 46 , 52 , 56 , 59 , 63 ] collected data after 2010.…”

“…Of the 18 studies that reported baseline Fisher grade, 14 studies [ 28 – 30 , 32 , 33 , 39 , 40 , 43 , 45 , 53 , 59 , 60 , 63 , 65 ] included a patient population with high disease severity, with most patients falling into the Fisher grade 3 category, which has the highest risk for VSP, DCI, and resulting poor outcomes [ 66 ]. Approximately two-thirds or more of patients from 18 studies [ 24 , 26 , 28 – 30 , 34 , 36 , 38 , 40 , 43 , 48 , 50 , 54 , 59 – 61 , 63 , 65 ] had a Hunt–Hess baseline score of ≤ 3 at hospital entry, corresponding to asymptomatic or minimal headache (grade 1), moderate-to-severe headache (grade 2), or drowsiness, confusion, or mild focal deficit (grade 3). Additionally, around half or more of patients from 4 studies [ 11 , 39 , 53 , 55 ] had a Hunt–Hess baseline score of ≥ 3 at hospital entry (grade 4 = stupor, moderate to severe hemiparesis; grade 5 = deep coma).…”

Hemodynamic response and clinical outcome following intravenous milrinone plus norepinephrine–based hyperdynamic hypertensive therapy in patients suffering secondary cerebral ischemia after aneurysmal subarachnoid hemorrhage

“…Forty years ago, HHH (hypervolemia, hypertension, hemodilution) therapy became the mainstay of treatment for vasospasm following subarachnoid hemorrhage [ 24 , 29 ]. Volume expansion using crystalloid and colloid solutions was subsequently discredited in a number of settings and further analysis for the case of subarachnoid hemorrhage indicated that hemodilution and plasma expansion added little to the effect of induced hypertension, or were even contra productive [ 4 , 22 ]. Milrinone became popular as an inotropic agent because of the associated vasodilation effects [ 12 ].…”

Fluid management in patients undergoing neurosurgery

“…Compared to the standard therapy group, the goal-directed fluid therapy (GDFT) with a HES bolus group showed reduced frequencies of vasospasm and cardiopulmonary complications [36]. A recent retrospective study compared SAH patients who received HES with those who received crystalloids and found no significant difference in RRT [37]. Another retrospective study showed no positive correlation between the cumulative doses of HES and serum creatinine in SAH patients who had a normal renal function and concluded that the administration of HES 6% 130/0.4 is safe in SAH patients without pre-existing renal insufficiency.…”