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And Low-Molecular-Weight Low-Substituted Hydroxyethyl Anesthesiology 2006; 105:1228–37 Copyright © 2006, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Effect of High- and Low-molecular-weight Low-substituted Hydroxyethyl Starch on Blood Coagulation during Acute Normovolemic Hemodilution in Pigs Caroline Thyes, M.D.,* Caveh Madjdpour, M.D.,* Philippe Frascarolo, Ph.D.,† Thierry Buclin, M.D.,‡ Marco Bu¨ rki,§ Andreas Fisch, Ph.D.,࿣ Marc-Alexander Burmeister, M.D.,# Lars Asmis, M.D.,** Donat R. Spahn, M.D., F.R.C.A.†† Background: Hydroxyethyl starches (HES) with lower impact HYDROXYETHYL starches (HES) are high-polymeric on blood coagulation but longer intravascular persistence are of glucose compounds obtained by hydrolysis and subse- clinical interest. The current study aimed to investigate in vivo quent hydroxyethylation from the waxy maize starch amy- the isolated effect of molecular weight on blood coagulation 1 during progressive acute normovolemic hemodilution. lopectin. Mean molecular weight is a major determinant of Methods: Twenty-four pigs were normovolemically hemodi- the physicochemical characteristics of HES preparations. luted up to a total exchange of 50 ml ⅐ kg؊1 ⅐ body weight؊1 of The latter characteristics are furthermore influenced by the HES 650/0.42 or HES 130/0.42. Serial blood sampling was per- molar substitution ratio, which expresses the average num- formed to measure HES plasma concentration and to assess ber of hydroxyethyl groups added per unit of glucose, and blood coagulation. Concentration–effect relations were ana- by their C2/C6 ratio, which refers to the site preference of lyzed by linear regression, followed by the Student t test on hydroxyethylation at the glucose subunit carbon atoms regression parameters. Results: Blood coagulation was increasingly compromised occurring mainly at positions C2 and C6, and to a lesser 2 toward hypocoagulability by acute normovolemic hemodilu- degree at position C3. tion with both treatments (P < 0.01). Significantly greater im- Hydroxyethyl starch solutions are considered as effec- and tive plasma volume expanders with respect to their (0.04 ؍ pact on activated partial thromboplastin time (P ؍ significantly stronger decrease of maximal amplitude (P colloid oncotic properties and thus are widely used in ؍ ؍ ␣ 0.04), angle (P 0.02), and coagulation index (P 0.02) was clinical practice as plasma substitutes.3,4 However, the seen after acute normovolemic hemodilution with HES 650/0.42 clinical use of HES is limited mainly by their potential to ؍ as compared with HES 130/0.42. Except for factor VIII (P 5 0.04), no significant differences between both treatments were negatively affect hemostasis. Impaired platelet function, observed when relating antihemostatic effects to HES plasma a type I von Willebrand–like syndrome with reduced concentrations (P > 0.05). A significantly lesser decrease of levels of factor VIII (FVIII) and von Willebrand factor hemoglobin concentration has been found with HES 650/0.42 (vWF) exceeding a mere hemodilution effect1,6,7 as well as compared with HES 130/0.42 (P < 0.01) in relation to HES as impaired coagulation measured by thromboelastogra- plasma concentrations. ® 8,9 Conclusion: High-molecular-weight HES (650/0.42) shows a phy (TEG ; Haemoscope Corporation, Niles, IL), have moderately greater antihemostatic effect than low-molecular- been reported. Because of several studies in patients weight HES (130/0.42) during acute normovolemic hemodilu- undergoing cardiac surgery showing increased bleeding tion. However, similar effects on hemostasis were observed and transfusion requirements as well as higher mortality with both treatments when observed antihemostatic effects after administration of HES 450/0.7 (Hespan; DuPont were related to measured HES plasma concentrations. In addi- Pharma, Wilmington, Germany),10–12 the US Food and tion, HES 650/0.42 may have a lower efficacy in immediately Drug Administration has recently issued a warning restoring plasma volume. against high-volume administration (Ͼ 20 ml/kg) of the latter HES solution.12 Previous studies investigating the * Research Fellow, † Research Associate, †† Professor and Chairman, Depart- ment of Anesthesiology, ‡ Private Docent and Consulting Physician, Division of antihemostatic effect of different HES solutions have Clinical Pharmacology and Toxicology, § Technical Assistant, Department of considered molecular weight to be the crucial factor in Experimental Surgery, University Hospital Lausanne. ࿣ Director Pharmaceutical 7,13,14 Development, B. Braun Medical SA, Crissier, Switzerland. # Private docent and determining the impact on hemostasis. However, Associate Professor of Anesthesiology, Vice President Research and Develop- this statement was limited by the fact that the reduction ment, B. Braun Melsungen AG, Melsungen, Germany. ** Head of Coagulation Laboratory, Division of Hematology, University Hospital of Zurich, Switzerland. of molecular weight of the tested HES solutions has been Received from the Department of Anesthesiology, University Hospital Lausanne associated with a concomitant reduction of molar sub- and University of Lausanne, Lausanne, Switzerland. Submitted for publication Janu- stitution. Although a systematic investigation of the ary 10, 2006. Accepted for publication July 31, 2006. Supported by departmental funds and B. Braun Medical SA, Crissier, Vaud, Switzerland. The funding by B. Braun blood coagulation–compromising effect of molecular was exclusively for the experiment and not personal. The publication of the current weight was lacking, the use of HES solutions with lower results did not require a formal authorization of the manufacturer but was discussed with all coauthors, including those being employees of B. Braun (Drs. Fisch and molecular weight and low molar substitution has been Burmeister). Drs. Burmeister and Fisch are employees of B. Braun AG, Melsungen, claimed to minimize the risk of coagulopathy. Contrary Germany, and Crissier, Switzerland, and Dr. Spahn is doing paid consulting for B. Braun Medical SA, Crissier, Switzerland. The Department of Anesthesiology of the to the former assumptions, a recent study revealed sim- University Hospital of Lausanne has done other research projects in collaboration ilar alterations of blood coagulation when high-molecu- with B. Braun AG, Melsungen, Germany, and Crissier, Switzerland, and has thereby received other funding in the past as well as educational funds from the competitor lar low-substituted HES was compared with low-molec- companies. ular low-substituted HES at equal molar substitution.15 Address correspondence to Dr. Spahn: Department of Anesthesiology, University Hospital Zurich, Zurich Ch-8091, Switzerland. [email protected]. Individual article Therefore, high-molecular low-substituted HES solutions reprints may be purchased through the Journal Web site, www.anesthesiology.org. may be expected to show an improved pharmacokinetic Anesthesiology, V 105, No 6, Dec 2006 1228 MOLECULAR WEIGHT OF HES AND BLOOD COAGULATION 1229 behavior with a prolonged initial half-life without an oratory measurements. A further catheter was placed in exaggerated compromise on blood coagulation.15 the carotid artery, allowing continuous measurement of Currently, the isolated effect of molecular weight on mean arterial blood pressure and blood withdrawal for blood coagulation has been examined only after hyper- arterial blood gas analyses. Via the contralateral carotid volemic hemodilution and with relatively low doses (20 artery, an arterial cannula (AS10V; Jostra AG, Hirrlingen, ml ⅐ kgϪ1 ⅐ body weight [BW]Ϫ1).15 Less is known about Germany) was inserted and connected to a cardioplegia the effects on in vivo whole blood coagulation after pump (SIII Double Head Pump; Sto¨ckert, Munich, Ger- intraoperative colloidal replacement of blood loss with many) for controlled withdrawal of blood for normovol- high- and low-molecular-weight low-substituted HES so- emic hemodilution. lutions. The aim of this study was to investigate in vivo Further monitoring of the animals included continuous the blood coagulation–compromising effect of HES so- three-lead electrocardiogram, heart rate reading, and lutions of varying molecular weights (HES 650/0.42 vs. temperature monitoring. In addition, a direct bladder HES 130/0.42) at equal molar substitution (0.42) during catheterization was performed for urine sampling. progressive acute normovolemic hemodilution (up to 50 ml ⅐ kgϪ1 ⅐ BW Ϫ1) in pigs. HES Characterization Hydroxyethyl starch solutions with different molecular weights (647 and 136 kd) but identical molar substitu- Materials and Methods tion (0.42) as well as identical C2/C6 ratio (5:1) were investigated. To ensure full identity of molar substitution The animal experiments were performed according to and hydroxyethylation pattern, both HES colloids were the guidelines of the Swiss Federal Veterinary Office. manufactured using the same raw HES preparation by The protocol was approved by the Veterinary Office of successive hydrolysis. Thin-boiling waxy maize starch the Canton of Vaud (Service Ve´te´rinaire, Lausanne, Can- was suspended in water, activated by means of sodium ton de Vaud, Switzerland). The study group consisted of hydroxide, and allowed to react with ethylene oxide for 24 pigs with a mean BW of 43 Ϯ 4 kg. The pigs were 2 h at 40°C. The amounts of waxy maize starch and fasted overnight but allowed free access to water. ethylene oxide were chosen to yield HES with a molar substitution of 0.42. This original HES with its
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