Dr.Panditrao goes on to explain the intricate details about volume therapy, colloids, tetra starches, potato versus corn starches their advantages and complications

2. DR. MRIDUL M. PANDITRAO
CONSULTANT
DEPARTMENT OF ANESTHESIOLOGY
RAND MEMORIAL HOSPITAL
FREEPORT
BAHAMAS

3. Classification of HES
Degree of Hydroxyethylation
 0.7 Hetastarch Hespan®, Plasmasteril®
 0.6 Hexastarch Elohes®
 0.5 Pentastarch HAES-Steril®, Pentaspan®, Hemohes®
 0.4 Tetrastarch Voluven® ,Venofundin® , Tetraspan®

4. Actual knowledge
Serumwerk Bernburg developed a HES 130/0.42/6,4:1 from a potato-based starch
BBraun and Serumwerk Bernburg market the product in saline and balanced
solutions
VOLUVEN VENOFUNDIN
TETRASPAN
Raw Material Waxy corn Potato
Molecular weight 130 kD 130 kD
Molar substitution 0.4 0.42
C2 : C6 9:1 6.4 : 1

5. Voluven vs Potato-based HES
Waxy maize based HES and potato-based HES
differ significantly in their chemical fine
structure:
– Degree of branching (amylose content)
– C2:C6 ratio
– Free and total phosphate
Their pharmacological and clinical equivalence
remains to be proven

6. Voluven vs Potato-based HES
Voluven is a better product because of
 Remains intra-vascularly for a longer
time
 Proven to have minimal interference with
coagulation
 Minimal or no influence on renal function
 Proven to improve microcirculation
As opposed
 Potato based may interfere in
coagulation

7. Need to replace volume
• In cases of severe blood loss:
Shock – Sepsis – Burns – Surgery - Trauma
• Where there is large loss of blood and fluid, the volume is
required to be replaced to maintain cardiac index and
oxygen delivery
• Saving of donor blood: elective surgery
• Therapeutic hemodilution: stroke, PAOD
• Volume preload in spinal anesthesia

8. Spinal Anaesthesia Pathophysiolo

9. Hypotension in SA
• The commonest complications associated with
spinal anesthesia are hypotension and
bradycardia [1]
• Hypotesnsion- common significant cause of
peri-operative morbidity and mortality
• Prior to SA- preloading with crystalloid is
recommended to reduce the incidence of
hypotension, although its value has been
questioned [2]

10. Plasma Volume Restoration: Crystalloids vs Colloids
Intra cellular Fluid Interstitial Fluid Intra vascular Fluid
25 - 28 L 10 - 11 L 3L
Trauma induced 2–3L 1L
fluid transfer 1L
0.2 L
0.8 L
Colloid
Infusion
1L
Crystalloid
Infusion Retention of all colloids is not same
1L

11. Crystalloids- General Disadvantages
• Crystalloid solutions- a short intravascular half-life
• Crystalloids- poor plasma volume expanders
• So, hypotension associated with spinal anesthesia cannot be
completely eliminated by crystalloid preloading
• Large volumes of crystalloid fluid decrease oxygen-carrying
capacity, and may increase the risk of pulmonary and
peripheral edema
• Colloid solutions which remain in the circulation for a longer
period seem to be an effective alternative.
[2. Anaesth Analg 1997; 84: 111-114]

12. Generations of starches
*

13. Colloids
• Improved hemodynamic effects
during spinal anesthesia after the
administration of colloid solutions [3,
4].
• However, the ideal fluid regimens for
elderly patients scheduled for spinal
anesthesia is controversial [4, 5, 6].

15. Our study
With this background in mind, study
was designed to compare the
efficacy of new generation HES
130/0.4 (Tetrastarch) with various
preloading solutions in overcoming
the problems of SAIH

16. • Ethics committee clearance
•Sixty adult patients
• Informed consent
•ASA I/II
• Randomized in 3 groups
•Both males/females
1) RL group
•Elective major orthopedic
2) Gelofusin group
Surgical procedures
3) Voluven group
•Under SA/EA+SA
• Demographically matched
•500 ml RL/300 ml Gelofusin/300 ml Voluven
•Infused within 20 minutes
•Planned regional technique achieved
•Monitoring continued- HR, MAP, ECG, SaO2
•O2 inhalation-not started till substantial fall i.e. SaO2 of 92-93%
(fall of 7-8%)
•Additional 500 ml RL/200 ml Gelofusin/200 ml Voluven infused

17. Comaprison of Mean MAP in 3 groups
96.2
97.4
100
86.88 87.79
90 81.91 79.29
80
70
60
50 Before SA
After SA
40
30
20
10 P < 0.05
0
RL Gelofusin Voluven

18. RESULTS
• MAP after SA was statistically significantly reduced in RL
group as compared to that in Voluven group (p < 0.05)
• MAP after SA was statistically significantly reduced in
Gelofusine group as compared to that in Voluven group
(p < 0.05)
• MAP rather improved in Voluven group after S A

19. % of patients requiring oxygen supplementation
50 50
45
40
35 30
30
25
%
20
15
10 5
5
0
RL Gelofusin Voluven

20. RESULTS
• 50% ( 10 pts.) in Gelofusin and 30% ( 6 pts.) in RL groups required
oxygen supplementation after S A
• Only 5% ( 1pt.) required oxygen supplementation after S A in
Voluven group
• Clinically no significant excessive oozing/ bleeding in any one of
the groups (inclusive of Voluven)
• 20 % ( 4 pts.) in Gelofusin group had allergic reactions like
shivering, rashes and hypotension

21. Mechanism!
• “Tetrastarch decreases viscosity, increases laminarity of
flow”
• Leads to improved microcirculation; peripheral as well as
pulmonary
• Improves gaseous exchange
• Confirmed by consistently high SaO2 values
• No requirement of additional O2 supplement

22. Recommended indications of
Tetrastarch
• Intra-operative stability for preloading before SA
• May improve circulation/ O2 delivery in vasculo-
compromised areas
• May be beneficial in micro-vascular problems :
ARDS, SHOCK etc.

24. ADDITIONAL INDICATIONS
 As an alternative to blood transfusion
 In burn patients to improve PCOP
 In neurosurgery patients to decrease
the viscosity of blood and to improve
the cerebro-vascular perfusion
 In the patients of Vascular Graft
surgeries to improve the patency of
graft

25. ADDITIONAL INDICATIONS
“JEHOVAH’S WITNESSES” : A novel
indication
• Absolute refusal to accept blood & blood
products !
• Extremely dilemmatic & peculiar situation
• Especially emergency, unplanned & life
saving surgery

26. SUMMARIZING
• TETRASTARCH GOOD PRE-LOADING
• IMPROVES SaO2
• IMPROVES MICRO – CIRCULATION
• NO INTERFERENCE WITH
COAGULATION
• EXCELLENT INTRA-OP COURSE
• REAL “BLOOD ALTERNATIVE”
• VERSATILITY AND CONSISTANCY