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Hetastarch administration during cesarean delivery in preeclampsia: is it associated with renal dysfunction?
Abstract Number: F-01
Abstract Type: Original Research
Background: Hydroxyethyl starch (HES) solutions such as hetastarch (6%) have been commonly used for the prevention or treatment of maternal hypotension in cesarean deliveries.(1) However, recent studies have associated HES with renal injury in critically ill nonpregnant patients (2) leading to an FDA black box warning.(3) Since preeclamptic patients may be at risk for mild renal impairment, we hypothesized that hetastarch use during cesarean delivery could exacerbate renal injury in this subpopulation of parturients.
Methods: We conducted a retrospective study of all cesarean deliveries with an ICD-9 code for preeclampsia (January 2011 to April 2015) who had preop and postop plasma creatinine measured. The grouping variable was whether any HES was administered (HES-Y vs HES-N). The primary endpoint was percentage change in plasma creatinine. Secondary endpoints were vasopressor dose, presence of postop pulmonary edema, use of blood/products and neonatal status (Apgar 1 and 5). Demographic data were age, BMI, parity, gestational age, type of anesthesia, diabetes and severity of preeclampsia. Paired creatinine data were assessed using a paired t-test. Primary and secondary endpoints were assessed using multivariate ANOVA, controlling for markers of severe maternal hemorrhage (EBL, change in hemoglobin, or any intraoperative blood administration). Demographic variables were assessed with 1-way ANOVA or χ2-test where appropriate.
Results: Paired creatinine values were available for 211/294 patients. Excluded patients were of more advanced gestation (36.1±3.4 weeks vs 33.6±4.5 weeks; p<0.0001) with lower preop creatinine (0.63±0.13mg/dL vs 0.77±0.46mg/dL; p= 0.006) and fewer cases of eclampsia (7/83 vs 27/211; p=0.001) and HELLP (1/83 vs 32/211; p=0.001). There were 84 patients in HES-Y and 127 in HES-N groups. Baseline and percentage change in creatinine were normally distributed. Plasma creatinine increased for both groups (HES-Y 13.1+/-21.5% rise; HES-N 14.3+/-21.3% rise), but there was no difference between groups before or after controlling for maternal hemorrhage. Hemoglobin fell more in the HES-Y group (mean difference 1.64±1.75g/dL vs 1.23±1.21g/dL; p=0.04). There was no difference in baseline creatinine, EBL or blood transfusion requirements between groups. Post hoc power analysis showed a 90% power to detect a 10% difference between groups.
Conclusions: This retrospective dataset indicates that even in preeclamptic parturients who may be more prone to renal dysfunction, hetastarch administration was not associated with evidence for additional renal dysfunction. The study was limited by the choice of effect measure, short duration of effect studied, lack of information about magnesium therapy and the retrospective design.
1. Riley ET et al. Anesth Analg. 1995; 81(4): 838–42.
2. Myburgh JA et al. N Engl J Med 2012;367:1901-11.