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Clinical impact of disinvestment in hydroxyethyl starch for patients undergoing coronary artery bypass surgery: a retrospective observational study

  • Michael Hong
  • Philip M. Jones
  • Janet Martin
  • Bob Kiaii
  • Ramiro Arellano
  • Davy Cheng
  • Ava A. John-Baptiste
Article

Abstract

Purpose

To examine the effect of discontinuing hydroxyethyl starch (HES) solutions on length of hospital stay, transfusion, risk of death, acute kidney injury (AKI), and dialysis.

Methods

We conducted a historical cohort study of linked administrative and clinical databases in patients undergoing coronary artery bypass surgery (CABG) on cardiopulmonary bypass. We used propensity scores to match patients who did not receive HES (after discontinuation) with patients exposed to HES (before discontinuation) and also controlled for albumin exposure. Hospital length of stay (the primary outcome) was analyzed using Fine-Gray proportional hazard regression, with hospital discharge as the outcome and death as a competing risk. Adverse outcomes were compared between matched patients using conditional logistic regression.

Results

We compared 1,085 propensity score-matched pairs (n = 2,170) from a pool of 2,757 patients. Discontinuation of HES was associated with shorter length of hospital stay, as evidenced by an increased probability of discharge (hazard ratio, 1.24; 95% confidence interval [CI], 1.14 to 1.35) and a reduced risk of red blood cell transfusion (odds ratio [OR], 0.68; 95% CI, 0.55 to 0.84), plasma transfusion (OR, 0.48; 95% CI, 0.34 to 0.66), and platelet transfusion (OR, 0.62; 95% CI, 0.44 to 0.87). Discontinuation of HES was not associated with in-hospital mortality (OR, 0.74; 95% CI, 0.36 to 1.54), AKI (OR, 0.84; 95% CI, 0.57 to 1.25), or dialysis (OR, 0.83; 95% CI, 0.25 to 2.73).

Conclusions

For patients undergoing CABG on cardiopulmonary bypass, discontinuation of HES was associated with reduced hospital length of stay and reduced blood product transfusion, without measurable change in renal failure, dialysis rate, or in-hospital mortality. Our results should be interpreted with caution, though we found no evidence of harms associated with discontinuing HES.

Trial registration

www.clinicaltrials.gov (NCT02329158); registered 31 December, 2014.

Répercussions cliniques du déclin de l’utilisation de l’amidon hydroxyéthile chez les patients subissant un pontage coronarien : une étude observationnelle rétrospective

Résumé

Objectif

Étudier les répercussions de l’arrêt des solutions d’amidon hydroxyéthile (HEA) sur la durée de séjour à l’hôpital, les transfusions, le risque de décès, les lésions rénales aiguës (LRA) et la dialyse.

Méthodes

Nous avons réalisé une étude de cohorte historique dans des bases de données liées, administratives et cliniques, sur des patients subissant une chirurgie de pontage coronarien sous circulation extracorporelle. Nous avons utlisé des scores de propension pour apparier des patients qui n’avaient pas reçu de HEA (après son arrêt) à des patients exposés au HEA (avant son arrêt) et avons également contrôlé l’exposition à l’albumine. La durée du séjour à l’hôpital (principal critère d’évaluation) a été analysée au moyen d’un modèle de régression proportionnelle du risque de Fine-Gray en utilisant le congé de l’hôpital comme aboutissement et le décès comme risque compétitif. Les évolutions défavorables ont été comparées entre patients appariés en utilisant un modèle de régression logistique conditionnelle.

Résultats

Nous avons comparé 1 085 paires de patients (n = 2 170) appariés en fonction du score de propension à partir d’une population de 2 757 patients. L’arrêt du HEA a été associé à une plus courte durée de séjour à l’hôpital, comme l’a montré une augmentation de la probabilité de congé (rapport de risque, 1,24; intervalle de confiance [IC] à 95 % : 1,14 à 1,35) et une baisse du risque de transfusion de globules rouges (rapport de cotes [OR], 0,68; IC à 95 %, 0,55 à 0,84), de transfusion de plasma (OR, 0,48; IC à 95 %, 0,34 à 0,66) et de plaquettes (OR, 0,62; IC à 95 %, 0,44 à 0,87). L’arrêt du HEA n’a pas été associé à la mortalité au cours de l’hospitalisation (OR, 0,74; IC à 95 %, 0,36 à 1,54), des LRA (OR, 0,84; IC à 95 %, 0,57 à 1,25) ou la dialyse (OR, 0,83; IC à 95 %, 0,25 à 2,73).

Conclusions

Pour les patients subissant un pontage coronarien sous circulation extracorporelle, l’arrêt du HEA a été associé à un raccourcissement de la durée de séjour à l’hôpital et à une diminution des transfusions de produits sanguins sans différence mesurable sur les taux d’insuffisance rénale, de dialyse ou de mortalité hospitalière. Nos résultats doivent être interprétés avec prudence bien que nous n’ayons pas trouvé de données probantes d’effets nuisibles associés à l’arrêt du HEA.

Enregistrement de l’essai clinique

www.ClinicalTrials.gov (NCT02329158). Enregistré le 31 décembre 2014.

Notes

Acknowledgements

We thank the following individuals for providing secure access to the data for this analysis: Lisa Creasor, Health Information Analyst, provided data from the Canadian Institute of Health Information (CIHI) Discharge Abstract Database; Suhair AlShanteer, Decision Support Consultant, Lila Neumann, Decision Support Coordinator, and Dominic Langley, Decision Support Director, provided data from PowerChart and the CIHI Case Cost Database; Sharon Mason, Cardiac Care Regional Coordinator, provided data from Cardiac Care Network Database; Stephanie Fox, Research Associate, provided data from the Cardiac Surgery Database; Laura Aseltine and Kathleen Eckert, Medical Lab Technologists, provided data from the Blood Transfusion Laboratory; and Andrew Cleland, Former Director of the Division of Clinical Perfusion, and John Paul Mousseau, Cardiovascular Perfusionist, provided data from the Perfusion Database. We would also like to thank Dr. Dan Lizotte, Assistant Professor at the University of Western Ontario, for technical advice; Hailey Saunders for administrative and technical support; and Lois Hayter, Manager of Administration and Finance in the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, for administrative support.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Michael Hong, Philip M. Jones, and Ava A. John-Baptiste contributed substantially to all aspects of this manuscript, including conception and design; acquisition, analysis, and interpretation of data; and drafting the article. Janet Martin, Bob Kiaii, Ramiro Arellano, and Davy Cheng contributed substantially to the conception and design of the manuscript. Bob Kiaii contributed substantially to the acquisition of data. Janet Martin contributed to the analysis of data. Janet Martin, Bob Kiaii, Ramiro Arellano, and Davy Cheng contributed substantially to the interpretation of data.

Disclosure of funding

This research was funded by an Internal Research Fund (IRF) from the Department of Anesthesia & Perioperative Medicine and the Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI). Ava John-Baptiste was supported by start-up funding from the Department of Anesthesia & Perioperative Medicine.

Supplementary material

12630_2018_1245_MOESM1_ESM.pdf (108 kb)
Supplementary material 1 (PDF 108 kb)
12630_2018_1245_MOESM2_ESM.pdf (39 kb)
Supplementary material 2 (PDF 38 kb)
12630_2018_1245_MOESM3_ESM.pdf (42 kb)
Supplementary material 3 (PDF 41 kb)

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Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Michael Hong
    • 1
  • Philip M. Jones
    • 1
  • Janet Martin
    • 2
  • Bob Kiaii
    • 3
  • Ramiro Arellano
    • 4
  • Davy Cheng
    • 5
  • Ava A. John-Baptiste
    • 6
    • 7
  1. 1.Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & DentistryWestern UniversityLondonCanada
  2. 2.Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI)Western UniversityLondonCanada
  3. 3.Division of Cardiac Surgery, Department of Surgery, Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  4. 4.Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  5. 5.Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI)Western UniversityLondonCanada
  6. 6.Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI)Western UniversityLondonCanada
  7. 7.The Western Centre for Public Health and Family MedicineLondonCanada

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