A prospective, randomized comparison of thromboelastographic coagulation profile in patients receiving lactated Ringer's solution, 6% hetastarch in a balanced-saline vehicle, or 6% hetastarch in saline during major surgery.

OBJECTIVES To compare the effects of lactated Ringer's solution (LR), 6% hetastarch in a balanced-saline vehicle (HS-BS), and 6% hetastarch in normal saline (HS-NS) on coagulation using thromboelastography. DESIGN Prospective, randomized double-blinded evaluation of previously published clinical trial. SETTING Tertiary-care medical center. PARTICIPANTS Patients undergoing elective noncardiac surgery with an anticipated blood loss >500 mL. A total of 90 patients were enrolled with 30 patients in each group. INTERVENTIONS Patients received a standardized anesthetic. LR, HS-BS, and HS-NS were administered intraoperatively based on a fluid administration algorithm. Hemodynamic targets included maintenance of arterial blood pressure, heart rate, and urine output within a predefined range. MEASUREMENTS AND MAIN RESULTS Thromboelastography variables for r time, k time, maximum amplitude, and alpha angle (mean +/- SD) were recorded at induction of anesthesia, at the end of surgery, and 24 hours postoperatively. Patients in the LR group showed a state of hypercoagulation at the end of surgery with reductions (p < 0.005) in r time (-3.8 +/- 6.7 mm) and k time (-1.7 +/- 2.5 mm). This state of hypercoagulation continued into the postoperative period. Patients in the HS-NS group showed a state of hypocoagulation with increases (p < 0.05) in r time (+6.2 +/- 8.5 mm) and k time (+1.7 +/- 3.9 mm) and a reduction in maximum amplitude (-8.0 +/- 9.8 mm) at the end of surgery. This state of hypocoagulation was reduced in the postoperative period. Patients in the HS-BS group showed no significant changes in coagulation status at end of surgery, with the smallest changes in r time (-0.3 +/- 4.1 mm), k time (+0.1 +/- 3.1 mm), maximum amplitude (-5.4 +/- 12.3 mm), and alpha angle (0.3 +/- 12.5 degrees ). CONCLUSION LR-treated patients exhibited a hypercoagulative profile that persisted into the postoperative period. HS-BS administration was associated with a lesser change in the coagulation profile compared with HS-NS, which was associated with a hypocoagulative state.

[1]  J. Douketis,et al.  Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials , 2001, The Lancet.

[2]  N. Shammas.  Pulmonary embolus after coronary artery bypass surgery: A review of the literature , 2000, Clinical cardiology.

[3]  E. Bennett-Guerrero,et al.  Comparison of intraoperative blood loss in patients undergoing major surgery using Hextend, Hespan and lactated Ringer's solution. , 1999 .

[4]  B. Phillips-Bute,et al.  Hextend[registered sign], a Physiologically Balanced Plasma Expander for Large Volume Use in Major Surgery: A Randomized Phase III Clinical Trial , 1999 .

[5]  P. Glass,et al.  Hextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group. , 1999, Anesthesia and analgesia.

[6]  U. Finsterer,et al.  Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. , 1999, Anesthesiology.

[7]  B. Phillips-Bute,et al.  Hextend (R), a physiologically balanced plasma expander for large volume use in major surgery: A randomized phase III clinical trial , 1999 .

[8]  A. Sarmiento,et al.  Thromboembolic prophylaxis with use of aspirin, exercise, and graded elastic stockings or intermittent compression devices in patients managed with total hip arthroplasty. , 1999, The Journal of bone and joint surgery. American volume.

[9]  P. D. Di Cesare,et al.  Thromboembolism After Hip and Knee Arthroplasty: Diagnosis and Treatment , 1998, The Journal of the American Academy of Orthopaedic Surgeons.

[10]  W. Bargar,et al.  Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. , 1998, Archives of internal medicine.

[11]  W. White,et al.  Cost‐Benefit and Efficacy of Aprotinin Compared with ε‐Aminocaproic Acid in Patients Having Repeated Cardiac Operations: A Randomized, Blinded Clinical Trial , 1997 .

[12]  B. Seifert,et al.  Effect of progressive haemodilution with hydroxyethyl starch, gelatin and albumin on blood coagulation. , 1997, British journal of anaesthesia.

[13]  M. James,et al.  Transumbilical insertion of saline-filled breast implants. , 1997 .

[14]  M. Durieux,et al.  Hydroxyethyl Starch: Safe or Not , 1997, Anesthesia and analgesia.

[15]  R. Morgan,et al.  Thrombelastographic evaluation of coagulation in transurethral prostatectomy. , 1996, British Journal of Urology.

[16]  M. James,et al.  Haemodilution induces a hypercoagulable state. , 1996, British journal of anaesthesia.

[17]  K. Ng,et al.  The Development of Hypercoagulability State, as Measured by Thrombelastography, Associated with Intraoperative Surgical Blood Loss , 1996, Anaesthesia and intensive care.

[18]  B. Rosenfeld,et al.  The influence of anesthetic method on infrainguinal bypass graft patency: a closer look. , 1995, The American surgeon.

[19]  R. Bick.  Evaluation of a New Hydroxyethyl Starch, Preparation (Hextend™) on Selected Coagulation Parameters , 1995 .

[20]  Perler Ba.  Hypercoagulability and the hypercoagulability syndromes. , 1995 .

[21]  A. Lee,et al.  A comparison of Plasmalyte 148 and 0.9% saline for intra‐operative fluid replacement , 1994, Anaesthesia.

[22]  H. Eichler,et al.  Effect of hydroxyethyl starch on the activity of blood coagulation and fibrinolysis in healthy volunteers: Comparison with albumin , 1994, Critical care medicine.

[23]  C. Tatooles,et al.  Aprotinin for coronary bypass operations: efficacy, safety, and influence on early saphenous vein graft patency. A multicenter, randomized, double-blind, placebo-controlled study. , 1994, The Journal of thoracic and cardiovascular surgery.

[24]  M. Hynynen,et al.  Hydroxyethyl starch as a prime for cardiopulmonary bypass: effects of two different solutions on haemostasis , 1993 .

[25]  G. Hempelmann,et al.  Influence of different intravascular volume therapies on platelet function in patients undergoing cardiopulmonary bypass. , 1993, Anesthesia and analgesia.

[26]  J. Paramo,et al.  Fibrinolytic activity in plasma after gynecological and urological surgery. , 1988, Haemostasis.

[27]  R. Strauss,et al.  Effects of hydroxyethyl starch on blood coagulation, particularly factor VIII , 1985, Transfusion.

[28]  R. Strauss,et al.  Effects of hydroxyethyl starch on fibrinogen, fibrin clot formation, and fibrinolysis , 1985, Transfusion.

[29]  R. Strauss,et al.  Hydroxyethyl starch accentuates von Willebrand's disease , 1985, Transfusion.

[30]  R. Greenhalgh,et al.  Postoperative deep vein thrombosis caused by intravenous fluids during surgery , 1980, The British journal of surgery.

[31]  M. Maxwell,et al.  Acid-base and electrolyte changes induced by acute isotonic saline infusion in the nephrectomized dog. , 1969, The Journal of laboratory and clinical medicine.

[32]  J. T. Cope,et al.  Intraoperative hetastarch infusion impairs hemostasis after cardiac operations. , 1997, The Annals of thoracic surgery.

[33]  S. Choi,et al.  Coagulopathy with the use of hetastarch in the treatment of vasospasm. , 1995, Journal of neurosurgery.

[34]  K. Fish,et al.  A cluster of severe postoperative bleeding following open heart surgery. , 1992, Infection control and hospital epidemiology.

[35]  J. Paramo,et al.  Changes in coagulation and fibrinolysis after total hip replacement and their relations with deep vein thrombosis. , 1985, Haemostasis.