Efficacy and safety of 6% hydroxyethyl starch 130/0.4 (Voluven) for perioperative volume replacement in children undergoing cardiac surgery: a propensity-matched analysis.

INTRODUCTION: Six percent hydroxyethyl starch (HES) 130/0.4 is considered an alternative to human albumin (HA) and crystalloids for volume replacement in children undergoing cardiac surgery. In this large propensity-matched analysis, we aimed to assess the efficacy and safety of replacing HA with HES for intraoperative volume therapy in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS: We retrospectively reviewed our database, including children who underwent cardiac surgery between January 2002 and December 2010. Four percent HA was used until 2005; it was replaced by HES thereafter. Demographic data, intra- and postoperative blood loss and blood component transfusions were recorded, together with the incidence of postoperative complications and mortality. We performed a propensity-matched analysis using 13 possible confounding factors to compare children who received either HES or HA intraoperatively. The primary objectives included the effects of both fluids on intraoperative fluid balance (difference between fluids in and fluids out (efficacy)) and blood loss and exposure to allogeneic blood products (safety). Secondary safety outcomes were mortality and the incidence of postoperative renal dysfunction. RESULTS: Of 1,832 children reviewed, 1,495 were included in the analysis. Intraoperative use of HES was associated with a less positive fluid balance. Perioperative blood loss, volume of red blood cells and fresh frozen plasma administered, as well as the number of children who received transfusions, were also significantly lower in the HES group. No difference was observed regarding the incidence of postoperative renal failure requiring renal replacement therapy or of morbidity and mortality. CONCLUSIONS: These results confirm that the use of HES for volume replacement in children during cardiac surgery with CPB is as safe as HA. In addition, its use might be associated with less fluid accumulation. Further large studies are needed to assess whether the reduction in fluid accumulation could have a significant impact on postoperative morbidity and mortality.

The indication for perioperative red blood cell transfusions is a predictive risk factor for severe postoperative morbidity and mortality in children undergoing cardiac surgery.

OBJECTIVES: In paediatric cardiac surgery, red blood cell (RBC) transfusions are given to treat haemorrhage or to increase oxygen delivery (therapeutic transfusion). Sometimes, RBCs are added to the prime solution to avoid a too low haematocrit on bypass (CPB-driven transfusion). Our study investigated whether the reason for RBC transfusion might affect severe postoperative morbidity or mortality. METHODS: This retrospective cohort study was conducted in a tertiary care level, children's hospital. The charts of all patients admitted between 2006 and 2009 were reviewed. Among transfused patients, children receiving a therapeutic transfusion were compared with those receiving a CPB-driven transfusion. The primary outcome was severe postoperative morbidity or mortality. Statistically significant variables founded with univariate analysis were incorporated in the multivariable logistic regression analysis to build a model that predicts severe postoperative morbidity or mortality. This model was then adjusted for clinically relevant variables that may interfere with 'indication for transfusion'. RESULTS: One hundred and one (48%) patients in the therapeutic and 92 (26%) patients in the CPB-driven transfusion group developed severe postoperative morbidity or died (P < 0.001). A multivariable logistic regression showed that weight, ASA, calculated blood loss, intraoperative fluid balance, duration of CPB time and the indication group for transfusion [1.64 (1.03-2.62); P = 0.039] were independent risk factors for severe postoperative morbidity or mortality. The indication group for transfusion remained significant [2.0 (1.16-3.45); P = 0.013] after adjustment for significant predictors of indication for transfusion. Number of patients with infections, or neurological deficit, and length of mechanical ventilation, PICU and hospital length of stay, were significantly higher in the therapeutic compared with the CPB-driven transfusion group one. CONCLUSIONS: The indication group for transfusion has an impact on the occurrence of severe postoperative morbidity or mortality in children undergoing cardiac surgery.