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Effects of hydroxyethyl starch 6 % (130/0.4) on blood loss during cesarean delivery: a propensity-matched analysis

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Abstract

Background

Hydroxyethyl starch is commonly used in the obstetric patient population to prevent hypotension during cesarean delivery. Evidence suggests hetastarch is associated with a dysfunction in coagulation cascade. We hypothesized that hetastarch use to prevent spinal hypotension during cesarean delivery would be associated with an increase in blood loss when compared to crystalloid use.

Methods

We performed a retrospective review of patients who underwent elective cesarean delivery under spinal anesthesia at the University of Virginia between 2011 and 2014. Data from 819 patients was used. Blood loss was the primary outcome. Propensity score-matching was used to match patients who received hetastarch (treatment group) with those who did not receive hetastarch (control group).

Results

Genetic matching resulted in 196 patients in the hetastarch group and 182 patients in the control group. There was no difference in estimated blood loss (p = 0.068), calculated blood loss (p = 0.720), total intraoperative fluid intake (p = 0.289), urine output (p = 0.421), Apgar 1 min (p = 0.830), Apgar 5 min (p = 0.138), phenylephrine consumption (p = 0.742), postoperative day 1 (POD1) hematocrit (p = 0.070) and POD1 platelets (p = 0.233). However, there was a statistically significant difference (but clinically irrelevant) in hematocrit difference between the day of admission and POD1 (mean difference 0.47, p = 0.024), and ephedrine consumption (mean difference 2 mg, p = 0.017) in favor of the control group.

Conclusions

Our study did not find an association between increased perioperative blood loss and hetastarch use in patients presenting for elective cesarean delivery.

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References

  1. Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev. 2006:CD002251.

  2. Mercier FJ. Cesarean delivery fluid management. Curr Opin Anaesthesiol. 2012;25:286–91.

    Article  CAS  PubMed  Google Scholar 

  3. Banerjee A, Stocche RM, Angle P, Halpern SH. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anaesth. 2010;57:24–31.

    Article  PubMed  Google Scholar 

  4. Agency MaHPR. Class 2 drug alert: hydroxyethyl starch (HES) products. http://www.mhra.gov.uk/Publications/Safetywarnings/DrugAlerts Accessed 18 Aug 2015.

  5. Food and Drug Administration. FDA Safety communication: boxed warning on increase mortality and severe kidney injury and additional warning on risk of bleeding fuohssi. http://www.fda.gov.biologicsbloodvaccines/safetyavailabilty/ucm358271.htm. Accessed 18 Aug 2015.

  6. Pharmacovigilance Risk Assessment Committee of the European Medicines Agency. http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Solutions_for_infusion_containing_hydroxyethyl_starch/European_Commission_final_decision/WC500162361.pdf. Accessed Aug 2015.

  7. Kozek-Langenecker SA. Influence of fluid therapy on the haemostatic system of intensive care patients. Best Pract Res Clin Anaesthesiol. 2009;23:225–36.

    Article  CAS  PubMed  Google Scholar 

  8. Kind SL, Spahn-Nett GH, Emmert MY, et al. Is dilutional coagulopathy induced by different colloids reversible by replacement of fibrinogen and factor XIII concentrates? Anesth Analg. 2013;117:1063–71.

    Article  CAS  PubMed  Google Scholar 

  9. de Jonge E, Levi M. Effects of different plasma substitutes on blood coagulation: a comparative review. Crit Care Med. 2001;29:1261–7.

    Article  PubMed  Google Scholar 

  10. de Jonge E, Levi M, Buller HR, Berends F, Kesecioglu J. Decreased circulating levels of von Willebrand factor after intravenous administration of a rapidly degradable hydroxyethyl starch (HES 200/0.5/6) in healthy human subjects. Intensive Care Med. 2001;27:1825–9.

    Article  PubMed  Google Scholar 

  11. Butwick A, Carvalho B. The effect of colloid and crystalloid preloading on thromboelastography prior to Cesarean delivery. Can J Anaesth. 2007;54:190–5.

    Article  PubMed  Google Scholar 

  12. Oh CS, Sung TY, Kim SH, Kim DK, Lim JA, Woo NS. Assessment of coagulation with 6 % hydroxyethyl starch 130/0.4 in cesarean section. Korean J Anesthesiol. 2012;62:337–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Turker G, Yilmazlar T, Mogol EB, Gurbet A, Dizman S, Gunay H. The effects of colloid pre-loading on thromboelastography prior to caesarean delivery: hydroxyethyl starch 130/0.4 versus succinylated gelatine. J Int Med Res. 2011;39:143–9.

    Article  CAS  PubMed  Google Scholar 

  14. Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion. 2003;43:459–69.

    Article  PubMed  Google Scholar 

  15. Skhirtladze K, Base EM, Lassnigg A, et al. 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. Br J Anaesth. 2014;112:255–64.

    Article  CAS  PubMed  Google Scholar 

  16. Terkawi AS, Mavridis D, Flood P, et al. does ondansetron modify sympathectomy due to subarachnoid anesthesia?: Meta-analysis, meta-regression, and trial sequential analysis. Anesthesiology. 2016;124:846–69.

    Article  CAS  PubMed  Google Scholar 

  17. Terkawi AS, Tiouririne M, Mehta SH, Hackworth JM, Tsang S, Durieux ME. Ondansetron does not attenuate hemodynamic changes in patients undergoing elective cesarean delivery using subarachnoid anesthesia: a double-blind, placebo-controlled, Randomized Trial. Reg Anesth Pain Med. 2015;40:344–8.

    Article  CAS  PubMed  Google Scholar 

  18. Ho DE, Imai K, King G, Stuart EA. Matching as nonparametric preprocessing for reducing model dependence in parametric causal inference. Polit Anal. 2007;15:199–236.

    Article  Google Scholar 

  19. Team RC. R: the R project for statistical computing. Vienna: R Foundation for Statistical Computing. https://www.r-project.org. Accessed 18 Aug 2015.

  20. Radice R, Ramsahai R, Grieve R, Kreif N, Sadique Z, Sekhon JS. Evaluating treatment effectiveness in patient subgroups: a comparison of propensity score methods with an automated matching approach. Int J Biostat. 2012;8:25.

    Article  PubMed  Google Scholar 

  21. Hill J, Reiter JP. Interval estimation for treatment effects using propensity score matching. Stat Med. 2006;25:2230–56.

    Article  PubMed  Google Scholar 

  22. Mercier FJ, Diemunsch P, Ducloy-Bouthors AS, et al. 6 % Hydroxyethyl starch (130/0.4) vs Ringer’s lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial. Br J Anaesth. 2014;113:459–67.

    Article  PubMed  Google Scholar 

  23. Riley ET, Cohen SE, Rubenstein AJ, Flanagan B. Prevention of hypotension after spinal anesthesia for cesarean section: six percent hetastarch versus lactated Ringer’s solution. Anesth Analg. 1995;81:838–42.

    CAS  PubMed  Google Scholar 

  24. Kozek-Langenecker SA. Effects of hydroxyethyl starch solutions on hemostasis. Anesthesiology. 2005;103:654–60.

    Article  PubMed  Google Scholar 

  25. Romdhani C, Trabelsi W, Lebbi A, et al. Lower incidence of hypotension following spinal anesthesia with 6 % hydroxyethyl starch preload compared to 9 ‰ saline solution in caesarean delivery. Tunis Med. 2014;92:406–10.

    PubMed  Google Scholar 

  26. Matsota P, Karakosta A, Pandazi A, Niokou D, Christodoulaki K, Kostopanagiotou G. The effect of 0.5 L 6 % hydroxyethyl starch 130/0.42 versus 1 L Ringer’s lactate preload on the hemodynamic status of parturients undergoing spinal anesthesia for elective cesarean delivery using arterial pulse contour analysis. J Anesth. 2015;29:352–9.

    Article  PubMed  Google Scholar 

  27. Teoh WH, Sia AT. Colloid preload versus coload for spinal anesthesia for cesarean delivery: the effects on maternal cardiac output. Anesth Analg. 2009;108:1592–8.

    Article  PubMed  Google Scholar 

  28. Corke BC, Datta S, Ostheimer GW, Weiss JB, Alper MH. Spinal anaesthesia for Caesarean section. The influence of hypotension on neonatal outcome. Anaesthesia. 1982;37:658–62.

    Article  CAS  PubMed  Google Scholar 

  29. Tamilselvan P, Fernando R, Bray J, Sodhi M, Columb M. The effects of crystalloid and colloid preload on cardiac output in the parturient undergoing planned cesarean delivery under spinal anesthesia: a randomized trial. Anesth Analg. 2009;109:1916–21.

    Article  CAS  PubMed  Google Scholar 

  30. McDonald S, Fernando R, Ashpole K, Columb M. Maternal cardiac output changes after crystalloid or colloid coload following spinal anesthesia for elective cesarean delivery: a randomized controlled trial. Anesth Analg. 2011;113:803–10.

    Article  CAS  PubMed  Google Scholar 

  31. Toledo P, McCarthy RJ, Hewlett BJ, Fitzgerald PC, Wong CA. The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg. 2007;105:1736–40.

  32. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol. 2008;199(519):e511–7.

    Google Scholar 

  33. Hernandez JS, Alexander JM, Sarode R, McIntire DD, Leveno KJ. Calculated blood loss in severe obstetric hemorrhage and its relation to body mass index. Am J Perinatol. 2012;29:557–60.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA

    Abdullah S. Terkawi, Jessica S. Sheeran & Mohamed Tiouririne

  2. Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia

    Abdullah S. Terkawi

  3. Outcomes Research Consortium, Cleveland, OH, USA

    Abdullah S. Terkawi

  4. Department of Obstetrics and Gynecology, University of Virginia, P.O. Box 800712, Charlottesville, VA, 22908, USA

    Sarah K. Larkin

  5. Department of Epidemiology, Columbia University, 772 West 168th Street, New York, NY, 10032, USA

    Siny Tsang

Authors
  1. Abdullah S. Terkawi
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  2. Sarah K. Larkin
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  3. Siny Tsang
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  4. Jessica S. Sheeran
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  5. Mohamed Tiouririne
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Corresponding author

Correspondence to Mohamed Tiouririne.

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Terkawi, A.S., Larkin, S.K., Tsang, S. et al. Effects of hydroxyethyl starch 6 % (130/0.4) on blood loss during cesarean delivery: a propensity-matched analysis. J Anesth 30, 796–802 (2016). https://doi.org/10.1007/s00540-016-2208-z

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  • DOI: https://doi.org/10.1007/s00540-016-2208-z

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