Cardiopulmonary bypass priming using a high dose of a balanced hydroxyethyl starch versus an albumin-based priming strategy

Abstract

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.

Conclusion: 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.