Cardiopulmonary bypass priming using a high dose of a balanced hydroxyethyl starch versus an albumin-based priming strategy.
BACKGROUND
The optimal priming solution for cardiopulmonary bypass (CPB) is unclear. In this study, we evaluated the influence of high-volume priming with a modern balanced hydroxyethyl starch (HES) preparation on coagulation, inflammation, and organ function compared with an albumin-based CPB priming regimen.


METHODS
In 50 patients undergoing coronary artery bypass grafting, the CPB circuit was prospectively and randomly primed with either 1500 mL of 6% HES 130/0.42 in a balanced electrolyte solution (Na(+) 140 mmol/L, Cl(-) 118 mmol/L, K(+) 4 mmol/L, Ca(2+) 2.5 mmol/L, Mg(++) 1 mmol/L, acetate(-) 24 mmol/L, malate(-) 5 mmol/L) (n = 25) or with 500 mL of 5% human albumin plus 1000 mL 0.9% saline solution (n = 25). Inflammation (interleukins [IL]-6, -10), endothelial damage (soluble intercellular adhesion molecule-1), kidney function (kidney-specific proteins alpha-glutathione S-transferase, neutrophil gelatinase-associated lipocalin), coagulation (measured by thrombelastometry [ROTEM, Pentapharm, Munich, Germany]), and platelet function (measured by whole blood aggregometry [Multiplate analyzer, Dynabyte Medical, Munich, Germany]) were assessed after induction of anesthesia, immediately after surgery, 5 h after surgery, and on the morning of first and second postoperative days.


RESULTS
Total volume given during and after CPB was 3090 +/- 540 mL of balanced HES and 3110 +/- 450 mL of albumin. Base excess after surgery was lower in the albumin-based priming group than in the balanced HES priming group (-5.9 +/- 1.2 mmol/L vs +0.2 +/- 0.2 mmol/L, P = 0.0003). Plasma levels of IL-6, IL-10, and intercellular adhesion molecule-1 were higher after CPB in the albumin-based priming group compared with the HES priming group at all time periods (P = 0.0002). Urinary concentrations of alpha-glutathione S-transferase and neutrophil gelatinase-associated lipocalin were higher after CPB through the end of the study in the albumin group compared with the balanced HES group (P = 0.00004). After surgery through the first postoperative day, thrombelastometry data (clotting time and clot formation time) revealed more impaired coagulation in the albumin-based priming group compared with the HES priming group (P = 0.004). Compared with baseline, platelet function was unchanged in the high-dose balanced HES priming group after CPB and 5 h after surgery, but it was significantly reduced in the albumin-based priming group.


CONCLUSIONS
High-volume priming of the CPB circuit with a modern balanced HES solution resulted in reduced inflammation, less endothelial damage, and fewer alterations in renal tubular integrity compared with an albumin-based priming. Coagulation including platelet function was better preserved with high-dose balanced HES CPB priming compared with albumin-based CPB priming.
Boldt
Joachim
J
Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, D-67063 Ludwigshafen, Germany. boldtj@gmx.net
Suttner
Stephan
S
Brosch
Christian
C
Lehmann
Andreas
A
Röhm
Kerstin
K
Mengistu
Andinet
A
D000209:Acute-Phase Proteins; D000368:Aged; D000418:Albumins / Q000008:administration & dosage* / Q000009:adverse effects; D015415:Biomarkers / Q000097:blood; D001777:Blood Coagulation / Q000187:drug effects; D001803:Blood Transfusion; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000379:methods*; D003102:Colloids / Q000008:administration & dosage* / Q000009:adverse effects; D001026:Coronary Artery Bypass; D003404:Creatinine / Q000097:blood; D004730:Endothelium, Vascular / Q000187:drug effects / Q000276:immunology; D005260:Female; D005982:Glutathione Transferase / Q000097:blood; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000008:administration & dosage* / Q000009:adverse effects; D007249:Inflammation / Q000209:etiology / Q000276:immunology; D018836:Inflammation Mediators / Q000097:blood; D018799:Intercellular Adhesion Molecule-1 / Q000097:blood; D016753:Interleukin-10 / Q000097:blood; D015850:Interleukin-6 / Q000097:blood; D007527:Isoenzymes / Q000097:blood; D007668:Kidney / Q000187:drug effects / Q000378:metabolism; D000071068:Lipocalin-2; D054834:Lipocalins / Q000097:blood; D008297:Male; D010952:Plasma Substitutes / Q000008:administration & dosage* / Q000009:adverse effects; D010974:Platelet Aggregation / Q000187:drug effects; D011446:Prospective Studies; D011518:Proto-Oncogene Proteins / Q000097:blood; D013997:Time Factors; D016896:Treatment Outcome
D000209:Acute-Phase Proteins; D000418:Albumins; D015415:Biomarkers; D003102:Colloids; D006895:Hydroxyethyl Starch Derivatives; C508609:IL10 protein, human; C508600:IL6 protein, human; D018836:Inflammation Mediators; D015850:Interleukin-6; D007527:Isoenzymes; C489506:LCN2 protein, human; D000071068:Lipocalin-2; D054834:Lipocalins; D010952:Plasma Substitutes; D011518:Proto-Oncogene Proteins; D018799:Intercellular Adhesion Molecule-1; D016753:Interleukin-10; D003404:Creatinine; D005982:Glutathione Transferase; C119995:glutathione S-transferase alpha