title: The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis.
abstract: BACKGROUND
  Recent studies in septic patients showed that adverse effects of hydroxyethyl starches (HESs) 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 on safety and efficacy endpoints in patients undergoing cardiac surgery.
  
  
  METHODS
  We searched the PubMed, Embase and Cochrane Central Register of Controlled Trials databases for randomised controlled trials (RCTs) in the English or German language comparing the use of 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 performed even 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: SMD, -0.06; 95% CI, -0.20, 0.08; P = 0.39; versus crystalloids: SMD, -0.05; 95% CI, -0.20, 0.10; P = 0.54). Similar results were found for transfusion needs. Lengths 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
  In this meta-analysis of RCTs, we 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 patients undergoing cardiac surgery. The safety data on coagulation with older starches raise some issues that need to be addressed in future trials.
authors.affiliation: Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Therapy, Harlaching Hospital, Munich Municipal Hospital Group, Munich, Germany. matthias.jacob@med.uni-muenchen.de.
authors.forename: Matthias
authors.initials: M
authors.lastname: Jacob
authors.affiliation: Department of Anesthesiology and Critical Care, Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Hospices Civils de Lyon, 28 avenue du Doyen Lépine, Lyon, Bron, Cedex 69677, France. jean-luc.fellahi@chu-lyon.fr.|Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, 69008, France. jean-luc.fellahi@chu-lyon.fr.
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Fellahi
authors.affiliation: Department of Anesthesiology, University Hospital of Munich, Nussbaumstrasse 20, Munich, 80336, Germany. daniel.chappell@med.uni-muenchen.de.
authors.forename: Daniel
authors.initials: D
authors.lastname: Chappell
authors.affiliation: Department of General Anesthesiology, Cleveland Clinic Main Campus, Mail Code E31, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. ak@or.org.
authors.forename: Andrea
authors.initials: A
authors.lastname: Kurz
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion / Q000379:methods / Q000706:statistics & numerical data; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D000077324:Crystalloid Solutions; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000008:administration & dosage*; D007552:Isotonic Solutions / Q000008:administration & dosage; D010952:Plasma Substitutes / Q000008:administration & dosage*; D016032:Randomized Controlled Trials as Topic / Q000379:methods
chemical_list: D000077324:Crystalloid Solutions; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D010952:Plasma Substitutes