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Safety and efficacy of peri-operative administration of hydroxyethyl starch in children undergoing surgery: A systematic review and meta-analysis

Thy, Michaël; Montmayeur, Juliette; Julien-Marsollier, Florence; Michelet, Daphné; Brasher, Christopher; Dahmani, Souhayl; Orliaguet, Gilles

European Journal of Anaesthesiology: July 2018 - Volume 35 - Issue 7 - p 484–495
doi: 10.1097/EJA.0000000000000780

BACKGROUND Hydroxyethyl starch (HES) solutions have shown their efficiency for intravascular volume expansion. A safety recommendation limiting their use in adult patients has recently been made.

OBJECTIVE To assess the efficacy and adverse effects of HES when administered intra-operatively to paediatric patients.

DESIGN Systematic review with meta-analyses. Data were analysed using classical mean differences [and their 95% confidence intervals (CIs)] and trial sequential analysis. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification was performed for all outcomes. Reviewers extracted valid data, including perioperative total fluid intakes, mortality, renal function, coagulation tests, blood loss and length of hospital and ICU stay.

DATA SOURCES Searches were performed in databases (Pubmed, Embase, Cochrane central register of controlled trials), clinical trials register, and open access journals not indexed in major databases.

ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) published before December 2016 involving paediatric patients who received 6% low molecular weight HES.

RESULTS Nine RCTs involving 530 peri-operative paediatric patients were analysed. Compared with other fluids, HES did not significantly modify the amount of peri-operative fluid administered [mean difference 0.04; 95% CI (−1.76 to 1.84) ml kg−1], urine output [mean difference −33; 95% CI (−104 to 38) ml kg−1] or blood loss [mean difference −0.09; (−0.32 to 0.15) ml kg−1]. Trial sequential analysis determined that the outcomes for peri-operative fluid and urine output were underpowered. All results were graded as very low quality of evidence.

CONCLUSION Intravascular volume expansion with low molecular weight 6% HES did not appear to modify renal function, blood loss or transfusion when administered to children during the peri-operative period. However, given the lack of statistical power and the very low GRADE quality of evidence, more high-quality RCTs are needed to explore these outcomes.

From the Department of Anaesthesia and Intensive Care, Necker Hospital (MT, JM, GO), Paris Descartes (Paris V) University (MT, JM, GO), Department of Anaesthesia and Intensive Care, Robert Debre Hospital (FJ-M, DM, SD), Denis Diderot (Paris VII) University, Paris, France (FJ-M, DM, SD), Department of Anaesthesia & Pain Management, Royal Children's Hospital (CB), Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia (CB), DHU Protect (SD) and EA 08 Paris-Descartes, Pharmacologie et Èvaluation des thérapeutiques chez l’enfant et la femme enceinte, Paris, France (GO)

Correspondence to Prof. Gilles Orliaguet, MD, PhD, Service d’Anesthésie Réanimation, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75743, France Tel: +33 144494458; fax: +33 144494170; e-mail:

Published online 3 February 2018

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© 2018 European Society of Anaesthesiology