Effect of hydroxyethyl starch 130/0.4 on blood loss and coagulation in patients with dual antiplatelet agents prior to off-pump coronary artery bypass graft surgery

Abstract

[한글]

[영문]As a result of eliminating the deleterious effect of cardiopulmonary bypass, compared with on-pump coronary artery bypass surgery, off-pump coronary artery bypass surgery (OPCAB) has a lesser effect on coagulopathy and postoperative bleeding. Clopidogrel and aspirin have been demonstrated to reduce cardiovascular complications in patients with coronary artery occlusive disease, which renders patients to higher risk of bleeding complications in patient requiring surgery, and thus, many patients maintain antiplatelet therapy before OPCAB. Hydroxyethyl starch (HES) solutions are used for intravascular volume expansion in limited range due to coagulopathy with large volume. The purpose of this study was to compare the effect of 6% HES 130/0.4, a newly developed HES solution with relatively lower molecular rate and substitution ratio, to crystalloid on blood loss and coagulation in patients recently treated with dual antiplatelet agents prior to OPCAB in a prospective, randomized trial.One hundred and four patients scheduled for OPCAB, who received clopidogrel and aspirin within 3 days of surgery were randomly allocated to infuse 6% HES 130/0.4 up to 30 ml/kg followed by crystalloid infusion (HES group, n = 51) or infuse crystalloid only (Crystalloid group, n = 53) during perioperative period. Fluid replacement was guided by cardiac index (> 2.2 l/min/m2) and mean pulmonary artery pressure (10-14 mmHg). Routine coagulation profiles and thromboelastography were measured before and 1 day after the surgery. Intraoperative hemodynamics and the use of cardiotonic drugs were recorded. The amount of perioperative blood loss, transfusion requirement and fluids balance were recorded until the following day of the surgery. Packed red blood cells were transfused when hematocrit level was <25%.Patients’ characteristics and operative data were similar between the groups. The amount of perioperative blood loss and transfusion requirement were not significantly different between the groups, while postoperative hematocrit at 24hrs after the surgery was significantly lower in the HES 130/0.4 group (crystalloid group 30.9 ± 3.5 % vs HES 130/0.4 group 28.3 ± 3.4 %, p < 0.001). There were trends for delayed beginning of blood coagulation and decreased degree of coagulation on TEG in the HES 130/0.4 group. HES 130/0.4 did not provide better hemodynamic stabilities and the use of cardiotonic drugs was not significantly different between the groups.Regarding cost effects and safety issues, HES 130/0.4 does not seem to provide benefit in patients continuously treated with both colpidogrel and aspirin before OPCAB.