The Impact of Hydroxyethyl Starches in Cardiac Surgery: A Meta-Analysis

Introduction

Recent studies in septic patients showed that adverse effects of hydroxyethyl starches (HES) possibly outweigh their benefits in severely impaired physiological haemostasis. It remains unclear whether this also applies to patient populations that are less vulnerable. In this meta-analysis we evaluated the impact of various HES generations in patients undergoing cardiac surgery on safety and efficacy endpoints.

Methods

We searched the databases PubMed, Embase and the Cochrane controlled trials register for randomised controlled trials (RCT) in English or German language comparing HES to any other colloid or crystalloid during open heart surgery.

Results

Blood loss and transfusion requirements were higher for older starches with mean molecular weights more than 200 kDa compared to other volume substitutes. In contrast, this effect was not observed with latest generation tetrastarches (130/0.4), which even performed better when compared to albumin (blood loss of tetrastarch versus albumin: standardised mean difference (SMD) -0.34; 95% CI -0.63, -0.05; P =0.02; versus gelatin -0.06; 95% CI -0.20, 0.08; P =0.39; versus crystalloids: -0,05; 95% CI -0.20, 0.10; P =0.54). Similar results were found for transfusion needs. Length of stay in the intensive care unit or hospital were significantly shorter with tetrastarches compared to gelatin (intensive care unit: SMD -0.10; 95% CI -0.15, -0.05; P =0.0002) and crystalloids (Hospital: SMD -0.52; 95% CI -0.90, -0.14; P =0.007).

Conclusions

This meta-analysis of RCTs could not identify safety issues with tetrastarches compared with other colloid or crystalloid solutions in terms of blood loss, transfusion requirements or hospital length of stay in cardiac surgery. The safety data on coagulation with older starches raises some issues that need to be addressed in future trials.