Low molecular starch versus gealtin plasma expander during CPB does it make a difference

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Low Molecular Starch Versus Gelatin Plasma Expander During CPB: Does It Make A Difference? Ricardo H Boks, BSc, Marianne J Wijers, Jan Hofland, MD, PhD, Johanna J M Takkenberg, MD, PhD and Ad J J Bogers, MD, PhD .

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Types of plasma expanders

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Prime additives Mannitol 20 g/l NaHCO3 1mol/l Aprotinin 1.5 ~ 2 KIU/l

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Overview Plasma expanders

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Characteristics Voluven® Lower Molecular weight then Elohaes,HES Short half life time 3-4 hours Maximum dosage of 50ml / Kg Bodyweight / 24h Less allergic then Gelatins 0.006% versus 0.038% No chance for Prions ? (BSE)

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Objective pilot study Is it possible to replace Gelofusin for Voluven without exceeding the maximum dosage of Voluven of 50ml/Kg/24 hours ?

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Criteria pilot study Population of 50 patients BSA ? 1.6 M2 Primary surgery CABG and Valves

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Patient demography

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Results use of plasma expanders per/post operative

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Transfused bloodproducts

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The total used volume of plasma expanders; Gelofusin, Elohaes and Voluven pre, per and post operation did not exceed 50ml/Kg/24 hours therefore replacement of Gelofusin for Voluven is possible. Conclusion Pilot

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Randomized study Gelatin versus Starch 130/4.0 Objective: To use a single type of synthetic plasma expander. Hypothesis: No difference effect on transfusion, urine production blood loss and fluid resistance.

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Methods Randomized study of 180 patients divided in a Gelatin group GPE and Starch 130/4.0 group LMSRL Stratified into 3 series of 60 patients of the routinely used oxygenators

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Materials Capiox RX-25 Terumo Duo CML Cobe Quadrox-D Jostra Biomedicus centrifugal pump or roller pump CPB circuit coated with X-coating or Safeline

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Materials en Methods Priming GPE group LMSRL group 1300 – 1500 ml Gelofusin 1000 ml Voluven + 300 – 500 ml Ringer 200 ml 200 g/l Mannitol 200 ml 200 g/l Mannitol 30 ml NaHCO3 1 mmol/l 30 ml NaHCO3 1 mmol/l 7500 IU Heparin on request Aprotinin 2 million KIU

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Inclusion and exclusion criteria BSA ?1.8 m2 Hemoglobin ? 6.0 mmol/l < 75 years Primary surgery

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Table 1. Patients Characteristics Patients Characteristics Variable, unit GPE (n=90) LMSRL (n=90) p Gender (m/f) 78 / 12 72 /18 Age (years) 64 ± 0.98 63 ± 1.04 ns Weight (Kg) 82 ± 1.4 83 ± 1.5 ns Length (cm) 175 ± 0.93 174 ± 0.83 ns BSA (M2) 1.97 ± 0.02 1.97 ± 0.02 ns CPB (minutes) 128 ± 5.0 133 ± 5.1 ns Aox (minutes) 84 ± 3.6 88 ± 4.1 ns CABG 54 52 AVR 12 11 MVR 13 14 CABG + AVR 11 13 ICU stay (hours) 22.9 ± 0.7 22.8 ± 0.7 ns

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Results AFR Oxygenator Variable Unit GPE (n=30) LMSRL (n=30 p Capiox RX-25® AFR mmHg/l/min 26 ± 0.3 24 ± 0.4 0.02 Jostra Quadrox-D® AFR mmHg/l/min 25 ± 0.6 26 ± 0.5 ns Cobe Duo CML ® AFR mmHg/l/min 44 ± 0.6 45 ± 0.9 ns Values are expressed as mean ± SEM

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Lactate mmol/l COP mmHg

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Fluid balance Values are expressed as mean ± SEM in ml

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Transfusion, Blood loss and Urine production Values are expressed as mean ± SEM in ml

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Conclusions No difference in blood loss, transfusion, urine production, AFR Lower need for plasma-expanders by using starch solutions only Ratio Ringer / LMS is important for the COP LMS can replace Gelatin for the prime of the CPB circuit

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