London M J, Ho J S, Triedman J K, Verrier E D, Levin J, Merrick S H, Hanley F L, Browner W S, Mangano D T
Department of Anesthesia, University of California, San Francisco.
J Thorac Cardiovasc Surg. 1989 May;97(5):785-97.
Pentastarch is a hydroxyethyl starch similar to hetastarch, but with a lower average molecular weight (264,000 versus 450,000) and fewer hydroxyethyl groups (molar substitution ratio = 0.45 versus 0.70). These characteristics result in enhanced enzymatic hydrolysis, faster renal elimination (initial intravascular half-life = 2.5 versus 25.5 hours), and less effect on coagulation. We report on a randomized clinical trial comparing the clinical efficacy and safety of 10% pentastarch (group P) for plasma volume expansion after cardiac operations with that of 5% serum albumin (group A). During the first 24 hours after arrival of the patient in the intensive care unit, colloid was infused to maintain a cardiac index of 2.0 L/m2 or more and a mean arterial pressure within 10% of the preinduction value. Group P (n = 50) received 1706 +/- 393 ml of colloid (mean +/- standard deviation) during this period, and group A (n = 44), 1794 +/- 341 ml (p = no significant difference). Hemodynamic responses to infusion were similar for both groups, although in group P a greater increase in both cardiac index (0.5 +/- 0.5 versus 0.3 +/- 0.5 L/min/m2 in group A, p less than 0.01) and left ventricular stroke work index (10.8 +/- 8.0 versus 5.8 +/- 6.0 gm-m/m2, p less than 0.01) was observed during infusion of the first 500 ml. There were no significant differences in any of the measured respiratory parameters (alveolar-arterial oxygen gradient, estimated shunt fraction, and effective pulmonary compliance). Hemodilution with colloid significantly reduced serum protein levels in group P by 24 hours postoperatively (4.0 +/- 0.6 versus 5.0 +/- 0.7 gm/dl in group A, p less than 0.05), although mean serum colloid osmotic pressure was similar (15.4 +/- 2.6 [P] versus 15.5 +/- 2.7 mmHg [A], p = no significant difference). There were no significant between-group differences in prothrombin time, activated partial thromboplastin time, platelet count, bleeding time, or coagulation factors (fibrinogen, V, VII, VIII, or IX) on postoperative days 1 and 7. Perioperative fluid balance, weight change, chest tube output, red blood, platelet, or fresh frozen plasma usage, reexploration for bleeding, and clinical outcome were also similar. These findings indicate that pentastarch is as safe and effective s 5% albumin for plasma volume expansion after cardiac operations with no apparent adverse effects on coagulation. If commercially available at a lower cost than albumin, it would appear to be a reasonable first choice for colloid therapy in this setting.
喷他淀粉是一种羟乙基淀粉，与贺斯淀粉相似，但平均分子量较低（264,000 对比 450,000）且羟乙基基团较少（摩尔取代率 = 0.45 对比 0.70）。这些特性导致酶促水解增强、肾脏清除更快（初始血管内半衰期 = 2.5 小时对比 25.5 小时）以及对凝血的影响较小。我们报告一项随机临床试验，比较 10%喷他淀粉（P 组）与 5%血清白蛋白（A 组）用于心脏手术后扩容的临床疗效和安全性。在患者入住重症监护病房后的最初 24 小时内，输注胶体以维持心脏指数≥2.0 L/m²以及平均动脉压在诱导前值的 10%以内。在此期间，P 组（n = 50）输注胶体 1706 ± 393 ml（均值 ± 标准差），A 组（n = 44）输注 1794 ± 341 ml（p = 无显著差异）。两组对输注的血流动力学反应相似，尽管在 P 组，在前 500 ml 输注期间观察到心脏指数（0.5 ± 0.5 对比 A 组的 0.3 ± 0.5 L/min/m²，p < 0.01）和左心室每搏功指数（10.8 ± 8.0 对比 5.8 ± 6.0 gm-m/m²，p < 0.01）均有更大幅度的增加。在任何测量的呼吸参数（肺泡 - 动脉氧梯度、估计分流分数和有效肺顺应性）方面均无显著差异。术后 24 小时，P 组用胶体进行血液稀释使血清蛋白水平显著降低（4.0 ± 0.6 对比 A 组的 5.0 ± 0.7 gm/dl，p < 0.05），尽管平均血清胶体渗透压相似（15.4 ± 2.6 [P] 对比 15.5 ± 2.7 mmHg [A]，p = 无显著差异）。术后第 1 天和第 7 天，两组在凝血酶原时间、活化部分凝血活酶时间、血小板计数、出血时间或凝血因子（纤维蛋白原、V、VII、VIII 或 IX）方面无显著组间差异。围手术期液体平衡、体重变化、胸管引流量、红细胞、血小板或新鲜冰冻血浆用量、再次手术止血以及临床结局也相似。这些发现表明，喷他淀粉在心脏手术后扩容方面与 5%白蛋白一样安全有效，且对凝血无明显不良影响。如果其成本低于白蛋白且可商业化获取，那么在这种情况下它似乎是胶体治疗的合理首选。
