Gastric intramucosal pH changes after volume replacement with hydroxyethyl starch or crystalloid in patients undergoing elective abdominal aortic aneurysm repair.
OBJECTIVE
Gastric intramucosal pH (pHi), a surrogate marker of tissue oxygenation, falls following abdominal aorta aneurysm (AAA) repair. We tested the hypothesis that volume replacement with a hydroxyethyl starch solution would result in better preserved splanchnic oxygenation than would volume replacement with crystalloid solutions.


METHODS
This was a prospective, randomized, nonblinded study set in a university-affiliated community hospital. Thirty patients undergoing elective AAA repair were studied. Patients were randomly selected to receive intraoperative and postoperative fluid replacement with either hetastarch or crystalloid. According to the study protocol, patients could not receive in excess of 3,000 mL of hetastarch. Tissue oxygenation was assessed indirectly by measuring pHi using a nasogastric tonometer. Hemodynamic, oxygenation, and pHi data were collected preoperatively, preclamp, before unclamping, at the end of the procedure and postoperatively for 24 hours. Coagulation parameters were determined preoperatively and postoperatively for 24 hours.


RESULTS
Fifteen patients were randomized to each group. There were 18 male and 12 female patients, whose mean age was 66 +/- 9 years. The intraoperative fluid balance was significantly greater in the crystalloid compared with the hetastarch group (4,194 +/- 1,500 mL v 2,949 +/- 1,123 mL; P = .05, 95% confidence interval [C] 23 to 2,519 mL). There were no significant differences in the amount of intraoperative blood loss or postoperative transfusion requirements between the two groups. The difference between the preoperative pHi and nadir was 0.07 +/- 0.03 in the hetastarch group compared with 0.13 +/- 0.04 in the crystalloid group (P = .001, Cl 0.03 to 0.09). By multivariate analysis the only variable that influenced the fall in pHi was the type of resuscitation fluid (F ratio of 7.63; P = .01). There were no significant differences in hemodynamic- and oxygenation-derived variables or coagulation parameters between the two groups of patients. The length of mechanical ventilation, intensive care unit, and hospital stay was comparable between the two groups of patients.


CONCLUSIONS
In patients undergoing major surgery, volume resuscitation with hydroxyethyl starch solutions may improve microvascular blood flow and tissue oxygenation.
Marik
P E
PE
Department of Critical Care Medicine, St Vincent Hospital, Fallon Clinic, Worcester, MA 01604, USA.
Iglesias
J
J
Maini
B
B
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001777:Blood Coagulation; D001784:Blood Gas Analysis; D000077324:Crystalloid Solutions; D017558:Elective Surgical Procedures; D005260:Female; D005440:Fluid Therapy; D005753:Gastric Mucosa / Q000737:chemistry*; D006760:Hospitalization; D006801:Humans; D006863:Hydrogen-Ion Concentration; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010314:Partial Thromboplastin Time; D010952:Plasma Substitutes; D011446:Prospective Studies; D011517:Prothrombin Time; D012121:Respiration, Artificial
D000077324:Crystalloid Solutions; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D010952:Plasma Substitutes