Hydroxyethyl Starch and Risk of Bleeding: The Missing Links
Bibliographic record
Abstract
To the Editor: Arellano et al. (1) compared hydroxyethyl starch (HES) 264/0.45 (Pentaspan®; Bristol-Myers Squibb, St. Laurent, Quebec) to 5% albumin in major reconstructive surgery and raised some interesting points. The authors' well-designed trial falls short because of inherent flaws and skewed randomization. As such, evidence regarding HES and its clinical effect on bleeding is inconclusive. The effects of HES on platelets, factor VIII activity, and von Willebrand factor are well-defined in vivo (2–4). This study showed a dose-related significant prolongation of activated partial thromboplastin time, international normalized ratio, and reduction in von Willebrand factor A, von Willebrand factor L, and factor VIII activity in the HES group. The poor predictability of these tests for surgical bleeding has been established (5–7). Estimated blood loss and correlation between the worst test results and blood loss or transfusion were absent. No patient required re-exploration for microvascular coagulopathy. Thrombin time, which is negatively affected by albumin, was not assayed for or reported (8,9). The demographic imbalances between the two groups may explain the increased transfusion rate in the HES group. The larger number of women in the HES group (58% versus 17%; P = 0.003) accounted for the differences in weight (P = 0.0003) and height (P = 0.02) between the groups. Smaller body mass and smaller blood volumes lead to higher transfusion rates. A larger sample could eliminate the gender and transfusion difference. The HES group received 15% more colloid (P = 0.003) and 20 mL/kg more of crystalloid (P = 0.12). This further dilutes clotting factors and increases activated partial thromboplastin time and international normalized ratio. Finally, estimated blood loss and the amount of transfused blood products were not reported. The concern regarding the effect of starches on coagulation remains in question. The thought that coagulopathy from HES led to bleeding is difficult to conclude from this article. In vitro assessment of both albumin and starch show prolongation of clotting parameters but the clinical impact is unclear. Finally, transfusion of blood products is not an accurate measure of bleeding (10,11). As more information on the effects of colloids on coagulation accrues, condemnation of one product or another based on questionable evidence reduces the limited repertoire of fluids to be used for intravascular volume resuscitation. Aryeh Shander, MD, FCCM, FCCP David Moskowitz, MD Department of Anesthesiology, Critical Care Medicine Pain Management, and Hyperbaric Medicine Englewood Hospital Englewood, NJ [email protected]
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.026 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.004 |
| Open science | 0.003 | 0.001 |
| Research integrity | 0.009 | 0.015 |
| Insufficient payload (model declined to judge) | 0.010 | 0.005 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".