The effect of hydroxyethyl starch 6% 130/0.4 compared with gelatin on microvascular reactivity
2016; Wiley; Volume: 71; Issue: 7 Linguagem: Inglês
10.1111/anae.13388
ISSN1365-2044
AutoresAnneliese Moerman, C. Eeckhout, Katrien V. Vanderstraeten, Filip De Somer, Yves Van Belleghem, Stefan De Hert,
Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoAnaesthesiaVolume 71, Issue 7 p. 798-805 Original ArticleFree Access The effect of hydroxyethyl starch 6% 130/0.4 compared with gelatin on microvascular reactivity A. Moerman, Corresponding Author A. Moerman Professor Department of Anaesthesiology, Ghent University Hospital, Gent, Belgium Correspondence to: A. Moerman Email: [email protected]Search for more papers by this authorC. Van Eeckhout, C. Van Eeckhout Specialty Trainee Department of Anaesthesiology, Ghent University Hospital, Gent, BelgiumSearch for more papers by this authorK. Vanderstraeten, K. Vanderstraeten Medical Student Ghent University, Gent, BelgiumSearch for more papers by this authorF. De Somer, F. De Somer Professor and Head of Perfusion Department of Cardiac Surgery, Ghent University Hospital, Gent, BelgiumSearch for more papers by this authorY. Van Belleghem, Y. Van Belleghem Professor Department of Cardiac Surgery, Ghent University Hospital, Gent, BelgiumSearch for more papers by this authorS. De Hert, S. De Hert Professor and Scientific Director Department of Anaesthesiology, Ghent University Hospital, Gent, BelgiumSearch for more papers by this author A. Moerman, Corresponding Author A. Moerman Professor Department of Anaesthesiology, Ghent University Hospital, Gent, Belgium Correspondence to: A. Moerman Email: [email protected]Search for more papers by this authorC. Van Eeckhout, C. Van Eeckhout Specialty Trainee Department of Anaesthesiology, Ghent University Hospital, Gent, BelgiumSearch for more papers by this authorK. Vanderstraeten, K. Vanderstraeten Medical Student Ghent University, Gent, BelgiumSearch for more papers by this authorF. De Somer, F. De Somer Professor and Head of Perfusion Department of Cardiac Surgery, Ghent University Hospital, Gent, BelgiumSearch for more papers by this authorY. Van Belleghem, Y. Van Belleghem Professor Department of Cardiac Surgery, Ghent University Hospital, Gent, BelgiumSearch for more papers by this authorS. De Hert, S. De Hert Professor and Scientific Director Department of Anaesthesiology, Ghent University Hospital, Gent, BelgiumSearch for more papers by this author First published: 16 February 2016 https://doi.org/10.1111/anae.13388Citations: 7 This article is accompanied an editorial by Svensen, Anaesthesia 2016; 71: 747–50. You can respond to this article at http://www.anaesthesiacorrespondence.com AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Summary We compared the effects on microvascular reactivity of hydroxyethylstarch (Volulyte®) and gelatin (Geloplasma®) during acute haemodilution. The hypothesis was that Volulyte would provide better microvascular reactivity than Geloplasma. Forty patients undergoing elective cardiac surgery were randomly assigned to receive either Volulyte or Geloplasma as the exclusive priming solution of the cardiopulmonary bypass. To evaluate microvascular reactivity, postocclusive reactive hyperaemia was examined before and after cardiopulmonary bypass. Microvascular reactivity assessments included the rate of the occlusion and reperfusion slopes and reperfusion times. After cardiopulmonary bypass, increases in reperfusion time were significantly smaller in the Volulyte group (3 (−27 to 9 [−35 to 33]%) vs 29 (−17 to 76 [−34 to 137]%) in the Geloplasma group, p = 0.02 between groups). Rate of reperfusion increased in the Volulyte group (26 (−17 to 43 [−59 to 357])%), whereas it decreased in the Geloplasma group (−22 (−47 to 16 [−84 to 113])%), p = 0.02 between groups. The shorter reperfusion times and increased reperfusion rate suggest that Volulyte maintains better microvascular reactivity than Geloplasma. Introduction During acute haemodilution, blood viscosity and functional capillary density (capillaries with red blood cell transit per unit surface) change considerably, jeopardising tissue survival due to local microscopic maldistribution of blood flow 1. Restoration of blood rheology is a key component in the management of tissue perfusion and oxygenation, independent of the restitution of oxygen-carrying capacity 2. Several studies have demonstrated that colloids improve oxygen transport and tissue oxygenation 3-5. Hydroxyethyl starch (HES) 130/0.4 is a third generation starch. The average molecular weight of 130 000 Daltons seems to be the optimal molecular size in terms of the time of onset and the extent of increase in tissue oxygenation 5. The increased viscosity maintained functional capillary density 5, and rheological conditions were enhanced by reduced red blood cell aggregation 6. It has also been suggested that HES 130/0.4 attenuates response to injury of the glycocalyx and sustains vascular barrier function 7. More microvessels were perfused and interstitial oedema formation was attenuated with the use of HES 130/0.4 7. In this study, we aimed to investigate the effect of haemodilution with HES 6% 130/0.4 in a balanced electrolyte solution (Volulyte®, Fresenius Kabi, Schelle, Belgium) on cerebral oxygen saturation and microvascular reactivity. We chose cardiopulmonary bypass as the model to test our hypothesis because cardiopulmonary bypass represents a unique clinical circumstance in which haemodilution can be effected in a controlled manner. We compared Volulyte with the standard cardiopulmonary bypass priming in our department, modified fluid gelatin (Geloplasma®, Fresenius Kabi). The hypothesis was that Volulyte provides better microcirculatory perfusion than Geloplasma by demonstrating faster and better flow restoration after a period of ischaemic stress. The effect of the priming solutions on microvascular reactivity was evaluated with near-infrared spectroscopy (NIRS). Methods This prospective, randomised, triple blinded study was approved by the Institutional Ethics Committee of Ghent University Hospital (ref: 2013/1085) and registered with EudraCT (ref: 2013-005209-30). The trial was registered at ClinicalTrials.gov (NCT02034682). After written, informed consent, forty adult patients scheduled for elective coronary artery bypass grafting surgery with moderate hypothermic (> 32°C) cardiopulmonary bypass without blood transfusion were recruited. Exclusion criteria were: ejection fraction < 25%; documented allergy to HES or gelatin; administration of HES or gelatin within the preceding 2 weeks; renal insufficiency (creatinine > 177 μmol.l−1), diabetes; significant hepatic disease (liver enzymes (aspartate transaminase, alanine transaminase) > 3x upper limit of normal); cerebrovascular disease; significant carotid artery stenosis (> 60%); peri-operative use of corticosteroids; and the need for vasopressor or inotrope therapy before surgery. An expected haematocrit on cardiopulmonary bypass of < 23% (calculated based on preoperative haematocrit, estimated blood volume and amount of cardioplegia) was also considered an exclusion criterion. All subjects needed to fast and refrain from nicotine 6 h before anaesthesia. On the morning of surgery, patients took their routine medication, except for angiotensin-converting enzyme inhibitors and angiotensin-2 antagonists. Patients received premedication with oral diazepam (5–10 mg). Standard monitoring consisted of: ECG; pulse oximetry; end-tidal oxygen, carbon dioxide and sevoflurane concentrations; bispectral index (BIS XP A-2000™; Covidien, Mansfield, MA, USA); and invasive arterial, central venous pressure and temperature measurement (Dräger Infinity C700; Dräger Medical GmbH, Lübeck, Germany). Arterial blood pressure was recorded continuously via a right radial artery catheter. Two disposable NIRS sensors (NIRO-200NX; Hamamatsu Photonics, Tokyo, Japan) were applied bilaterally to the patient's forehead for continuous recording of cerebral oxygen saturation, and one sensor (NIRO-200NX; Hamamatsu Photonics) was applied circumferentially on the left forearm (over the brachioradialis muscle, approximately 5 cm distal from the proximal head of the radius) for measurement of tissue oxygen saturation and microvascular reactivity. Patients were randomly assigned to receive either Volulyte (n = 20) or Geloplasma (n = 20) as the exclusive priming solution. Assignment to the groups was determined by random drawing of consecutively numbered envelopes containing the labels Volulyte or Geloplasma. The perfusionist opened the envelope and covered the solution in an opaque non-transparent bag. All other caregivers were blinded to the randomisation. All data analysis was also done with masking maintained. Anaesthesia was induced with fentanyl 5 μg.kg−1, diazepam 0.1 mg.kg−1, rocuronium 1 mg.kg−1. The lungs were ventilated mechanically with oxygen enriched air (FIO2 0.6) adjusted to keep the end-tidal carbon dioxide around 5 kPa. Boluses of fentanyl up to a total dose of 25–35 μg.kg−1 were used for analgesia and anaesthesia was maintained with sevoflurane at a minimum concentration of 1.5%. Only crystalloid solutions (Plasmalyte A Viaflo, Baxter, Lessines, Belgium) were used before cardiopulmonary bypass was established. Cardiopulmonary bypass was performed with a roller pump (S5, Sorin group, München, Germany) providing non-pulsatile flow at 2.5 l.min−1.m−2. The priming consisted of 1200 ml study colloid, heparin 2500 IU and mannitol 0.5 g.kg−1. Alpha-stat acid-base gas management was used, and the target ranges for arterial oxygen partial pressure (PaO2) and arterial carbon dioxide partial pressure (PaCO2) were 25 kPa and 5 kPa, respectively. During cardiopulmonary bypass, phenylephrine or sodium nitroprusside were used, if necessary, to maintain perfusion pressure between 60 mmHg and 80 mmHg. After cardiopulmonary bypass, volume replacement was established with the blinded study colloid and/or cell saver blood. Doses of any drugs and fluids given were recorded. Microvascular reactivity was evaluated with postocclusive reactive hyperaemia (PORH). A sphygmomanometer cuff was wrapped around the arm over the left brachial artery. Arterial occlusion was achieved by inflating a standard blood pressure cuff (EH50U, Siemens) on the upper arm to a pressure of 50 mmHg above the individual systolic pressure of each subject. The cuff was automatically inflated in less than two seconds to the pressure needed for arterial occlusion. After three minutes of ischaemia, cuff pressure was rapidly released and the tissue oxygen saturation response was recorded. Cerebral and tissue oxygen saturations were recorded continuously. Microvascular reactivity was measured just after heparinisation (pre cardiopulmonary bypass) and at skin closure (post-cardiopulmonary bypass). To assess the effect of the priming solution on microvascular reactivity, the following parameters were determined by two investigators blinded to the groups (CVE and KV) 3, 8-10: Occlusion slope, change from baseline to minimum value per minute Time from release of the cuff to the initial value (expressed in seconds) Time from release of the cuff to the maximum value (expressed in seconds) Reperfusion slope, change from minimum to maximum value per minute A typical trace of a PORH measurement is shown in Fig. 1. Figure 1Open in figure viewerPowerPoint Typical trace of a postocclusive reactive hyperaemia measurement. Inflation of the cuff produces a decrease in oxygenated haemoglobin (red line) and tissue oxygen saturation (green line), and an increase in de-oxygenated haemoglobin (blue line). Total blood volume remains unaltered (white line). After release of the occluding cuff, blood volume increases rapidly, causing a rapid increase in oxygenated haemoglobin and a washout of de-oxygenated haemoglobin. Dotted line: reperfusion slope; solid line: time from release cuff to initial value. Time axis in minutes. Other variables included continuous measurement of cerebral oxygen saturation, blood gases (haemoglobin, PaO2, PaCO2, arteriovenous carbon dioxide partial pressure difference (PavCO2), pH and lactate) at the different times, and haemodynamic parameters, urinary output and the use of vasoactive medication during and after cardiopulmonary bypass. Pre- and postoperative creatinine, and postoperative troponin T were assessed. All intra- and postoperative adverse events were recorded. Prior studies demonstrated differences in reperfusion slope of 15–25% between healthy and subjects with cardiac disease 10-12. We, therefore, considered a difference of 20% in reperfusion slope between the two arms as clinically significant. Based on the reported mean reperfusion slope of 5.38%.s−1 with a SD of 1.32%.s−1 13, and accepting a two-tailed α error of 0.05 and a β error of 0.8, 18 patients were calculated to be required in each arm. To compensate for missing data or potential dropouts, we set the group size to 20 patients per group. Distribution of data was tested for normality using the Shapiro–Wilk test. Baseline characteristics, laboratory values and postoperative complications were analysed using independent samples t-test and Chi square test, as appropriate. Between group differences in PORH parameters and in intra-operative variables were assessed with the Mann–Whitney U-test. Cerebral oxygen saturations were analysed with paired t-test and independent samples t-test for within and between group differences, respectively. Statistical significance was accepted at p < 0.05. Results All 40 patients completed the study. Baseline characteristics and preoperative laboratory values were similar between the two groups (Table 1). Table 1. Baseline characteristics and pre-operative values of patients receiving Geloplasma or Volulyte as the priming solution for cardiopulmonary bypass. Values are mean (SD) or number Geloplasma Volulyte Age; years 65 (9) 68 (10) Weight; kg 74 (15) 80 (16) Height; m 1.70 (0.1) 1.69 (0.107) Gender (M/F) 15/5 18/2 Smoking 5 4 Haemoglobin; g.l−1 141 (12) 147 (16) SaO2; % 96 (1) 96 (1) SvO2; % 65 (21) 53 (22) PaO2; kPa 11 (1) 10 (1) PvO2; kPa 5 (2) 4 (1) PavCO2; kPa 0.9 (0.8) 1.4 (0.8) pH 7.4 (0.0) 7.4 (0.0) Lactate; mmol.l-1 1.2 (0.4) 1.3 (0.2) Creatinine; μmol.l-1 72 (14) 82 (19) With the exception of a small difference for de-oxygenated haemoglobin in the reperfusion time from release of the cuff to the maximum value, PORH parameters were not statistically different between the two groups before cardiopulmonary bypass (Table 2). Table 2. Postocclusive reactive hyperaemia parameters just before cardiopulmonary bypass in patients receiving Geloplasma or Volulyte as the priming solution for cardiopulmonary bypass. Values are median (IQR [range]) Geloplasma Volulyte p value Occlusion slope OxyHb; μmol.l−1.min−2 51 (4–100 [0–133]) 64 (3–93 [1–139]) 0.89 HHb; μmol.l−1.min−2 77 (18–109 [1–139]) 86 (4–109 [1–131]) 0.88 TOI; %.min−1 12 (10–16 [4–24]) 13 (9–14 [4–19]) 0.84 Time from release cuff to initial value OxyHb; s 11 (7–15 [2–22]) 13 (10–19 [6–49]) 0.23 HHb; s 20 (14–27 [8–36]) 22 (17–32 [15–66]) 0.36 TOI; s 13 (11–20 [6–36]) 15 (12–24 [8–50]) 0.25 Time from release cuff to maximum value OxyHb; s 30 (23–43 [17–54]) 37 (27–52 [21–115]) 0.08 HHb; s 49 (41–57 [34–81]) 56 (51–79 [43–103]) 0.03 TOI; s 35 (27–46 [17–79]) 39 (27–58 [19–97]) 0.40 Reperfusion slope OxyHb; μmol.l−1.min−2 482 (56–1025 [8–1776]) 358 (42–723 [5–1466]) 0.39 HHb; μmol.l−1.min−2 373 (40–648 [4–763]) 211 (21–438 [6–667]) 0.15 TOI; %.min−1 161 (73–273 [35–1034]) 119 (72–272 [20–427]) 0.63 OxyHb, oxygenated haemoglobin; HHb, de-oxygenated haemoglobin; TOI, tissue oxygenation index. The changes in PORH parameters in the two groups before and after cardiopulmonary bypass are shown in Table 3. There were no differences between the two groups in the occlusion slope. Changes in reperfusion times (from release of cuff to initial value or to maximum value) were significantly smaller in the Volulyte group. After cardiopulmonary bypass, the reperfusion slope increased in the Volulyte group, whereas it decreased in the Geloplasma group (Fig. 2). Table 3. Changes in postocclusive reactive hyperaemia parameters before and after cardiopulmonary bypass, in patients receiving Geloplasma or Volulyte as the priming solution of the cardiopulmonary bypass. Values are median (IQR [range]) Geloplasma Volulyte p value Occlusion slope (% change) OxyHb 30 (7 to‒46 [−23 to 897]) 9 (−4 to 27 [−24 to 66]) 0.10 HHb 14 (2 to‒31 [−12 to 60]) 16 (0 to‒28 [−11 to 43]) 0.99 TOI 5 (−5 to 24 [−44 to 39]) 7 (−4 to 19 [−40 to 68]) 0.97 Time from release cuff to initial value (% change) OxyHb 35 (3 to‒114 [−29 to 300]) 11 (−27 to 39 [−59 to 150]) 0.05 HHb 12 (−19 to 97 [−48 to 325]) −13 (−24 to 7 [−53 to 23]) 0.05 TOI 23 (−8 to 83 [−39 to 154]) −21 (−29 to 12 [−53 to 64]) 0.006 Time from release cuff to maximum value (% change) OxyHb 39 (−15 to 84 [−56 to 152]) −7 (−16 to 15 [−39 to 38]) 0.03 HHb 34 (−6 to 51 [−27 to 213]) −4 (−16 to −2 [−42 to 27]) 0.002 TOI 29 (−17 to 76 [−34 to 137]) 3 (−27 to 9 [−35 to 33]) 0.02 Reperfusion slope (% change) OxyHb −6 (−37 to 10 [−85 to 388]) 11 (−13 to 26 [−31 to 69]) 0.12 HHb −18 (−36 to 18 [−59 to 643]) 16 (−3 to 22 [−24 to 77]) 0.01 TOI −22 (−47 to 16 [−84 to 113]) 26 (−17 to 43 [−59 to 357]) 0.02 OxyHb, oxygenated haemoglobin; HHb, de-oxygenated haemoglobin; TOI, tissue oxygenation index. Figure 2Open in figure viewerPowerPoint Percentage change in reperfusion slopes after cardiopulmonary bypass in the Geloplasma group (plain boxes) and the Volulyte group (hatched boxes). OxyHb; oxygenated haemoglobin. HHb; de-oxygenated haemoglobin. TOI; tissue oxygenation index. The reperfusion slope decreased in the Geloplasma group, while it increased in the Volulyte group. The horizontal line in the box represents the median, the box represents the interquartile range and the vertical lines represent the range. Cerebral oxygen saturation values did not change after cardiopulmonary bypass, and were not different between the two groups. Intra-operative variables are shown in Table 4. There were no differences between the two groups. None of the patients needed allogeneic blood products. There were no differences between the two groups in post cardiopulmonary bypass laboratory values (Table 5). Table 4. Intra-operative variables with Geloplasma or Volulyte as the priming solution for cardiopulmonary bypass (CPB). Values are median (IQR [range]) Geloplasma Volulyte p value CPB time; min 82 (68–95 [47–128]) 77 (63–89 [43–118]) 0.44 Aortic cross-clamp time; min 47 (39–54 [21–64]) 47 (34–61 [22–100]) 0.75 Number of grafts 3 (3–4 [2–5]) 3 (2–4 [2–5]) 0.74 Fluid balance during CPB; ml 745 (455–1013 [160–1280]) 850 (560–1005 [105–1690]) 0.64 Colloids post-CPB; ml 0 (0–400 [0–550]) 0 (0–275 [0–750]) 0.93 Cell saver blood post-CPB; ml 0 (0–125 [0–250]) 0 (0–126 [0–500]) 0.46 Diuresis post-CPB; ml 162 (106–207 [70–460]) 225 (122–295 [60–500]) 0.07 Table 5. Laboratory values after cardiopulmonary bypass in patients receiving Geloplasma or Volulyte as the priming solution for bypass. Values are mean (SD) Geloplasma Volulyte p value Hb g.l−1 104 (12) 109 (12) 0.20 SaO2; % 99 (1) 98 (2) 0.06 SvO2; % 78 (6) 77 (6) 0.47 PaO2; kPa 28 (12) 22 (11) 0.11 PvO2; kPa 6 (1) 6 (1) 0.42 PavCO2; kPa 0.7 (0.4) 0.8 (0.4) 0.86 pH 7.4 (0.0) 7.4 (0.0) 0.62 BE; mmol.l−1 −0.7 (1.9) 0.3 (2.2) 0.14 Bicarbonate; mmol.l-1 23.9 (2.2) 25.2 (2.2) 0.06 Lactate; mmol.l−1 2.0 (0.6) 1.8 (0.4) 0.19 Creatinine; μmol.l−1 77 (17) 84 (25) 0.23 Troponin T; μg.l−1 0.77 (0.90) 0.60 (0.42) 0.44 No differences in postoperative complications were noted between the two groups (p = 0.48). Eleven patients in the Geloplasma group needed diuretics for oliguria or oedema, vs. eight in the Volulyte group (p = 0.36). One patient in the Volulyte group had postoperative respiratory deterioration due to pneumonia and died on the 25th postoperative day. In 7 and 11 patients in the Geloplasma and Volulyte groups, respectively (p = 0.34), the postoperative course was uneventful. Discussion After cardiopulmonary bypass, changes in reperfusion times were significantly smaller and rate of reperfusion was significantly faster in the Volulyte group, suggesting that Volulyte maintains better microcirculatory reactivity than Geloplasma. The safety of HES has been extensively debated 14. In critically ill patients, HES preparations were apparently associated with increased mortality and acute kidney injury as compared with crystalloids 15, 16. However, it must be noted that pathophysiology in critically ill patients differs markedly from surgical patients. Recent work has demonstrated that haemodilution with colloids leads to less renal injury than crystalloid haemodilution 17, and two meta-analyses in surgical patients concluded that there was no increase in the incidence of postoperative death and/or renal dysfunction with the use of HES 6% 130/0.4 18, 19. Investigation of the impact of various HES solutions on safety and efficacy endpoints in cardiac surgery revealed no safety issues with HES 130/0.4 in terms of blood loss, transfusion requirements or hospital length of stay 20. Our results suggesting better microcirculatory indices with HES 130/0.4 are in accordance with previous research. In a randomised trial in patients undergoing minor lower extremity surgery, ischaemia reperfusion injury was absent in the group receiving HES 130/0.4, whereas it was significant in those receiving 0.9% saline 21. In a pig model of colon anastomosis surgery, HES 130/0.4 fluid therapy significantly increased microcirculatory blood flow and tissue oxygen tension in healthy and injured colon compared with crystalloid fluid therapy 22. The use of HES 130/0.4 significantly improved internal organ perfusion and tissue oxygenation, as measured by gastric mucosal pH, when compared with HES 200/0.5 in 30 patients undergoing liver surgery 4. Microvascular reactivity can be assessed by quantification of the PORH response. Inducing a short period of ischaemia releases endogenous nitric oxide from the microvascular endothelium, dilating pre-capillary arterioles 23. Subsequent reperfusion favours opening of previously closed capillaries (recruitment) and increases blood flow in previously patent capillaries. The capability of the microcirculation to recruit the microvascular network can be used as a surrogate for microvascular integrity 24-26. Near-infrared spectroscopy has been validated as a reliable non-invasive method for quantification of the PORH response 8, 13, 27-29. Although this method does not directly measure microcirculatory blood flow, it enables quantification of physiological endpoints of tissue perfusion 24-26. A significant relationship between NIRS-derived microcirculatory indices and global indices of organ perfusion has been demonstrated in a variety of clinical settings, with significantly higher microcirculatory indices in survivors compared with non-survivors 24, 26, 29, 30. The results of this study should be interpreted within the constraints of the methodology. Near-infrared spectroscopy does not calculate absolute values and has to be regarded as a trend monitor. Therefore, we analysed changes in NIRS variables instead of absolute values. No differences were noted between the two groups with regard to postoperative complications or other parameters such as lactate, creatinine, troponin and diuresis. Although the power of the present study is insufficient to enable any definite conclusions with regard to outcome, it has to be acknowledged that clinical indices, such as oliguria, or biochemical markers, such as lactate, are late markers of tissue malperfusion. Recently, microcirculation has gained increased attention for the assessment of early physiological response in surgical patients. Cardiopulmonary bypass was chosen as the model to test our hypothesis because it enables haemodilution in a controlled manner. Although many additional factors related to cardiopulmonary bypass might have a negative impact on microcirculatory perfusion, haemodilution has a central role 31 and, therefore, we consider cardiopulmonary bypass to be a valid model. In conclusion, patients undergoing acute haemodilution during cardiopulmonary bypass have better microvascular reactivity with the use of Volulyte compared with Geloplasma. Funding This work was supported by the Department of Anaesthesiology, Ghent University Hospital, Ghent, Belgium. Competing interests AM has received lecture fees from Covidien (INVOS) and Sorin (NIRO). SDH has received lecture fees from Fresenius Kabi. All other authors have no conflicts of interest. 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Journal of Cardiothoracic and Vascular Anesthesia 2011; 25: 784– 90. Citing Literature Volume71, Issue7July 2016Pages 798-805 FiguresReferencesRelatedInformation
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