Blood Volume Expanders: Voluven™

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(Arnold: The Ultimate Total Body Volume Expander…)

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Editor’s Note:

I got an email today asking me if I knew anything about using Voluven as a replacement for Albumin as a prime constituent for the ECC. When looking it up, the obvious similarities to Hespan (Hetastarch), is that they both are synthetic BVE’s.


The primary difference I could discern was that Voluven is metabolized faster than comparable hydroxyethyl starch products.


I know from practical experience, that most of the physicians I have worked with, are very reluctant to employ Hetastarch when there is a need for volume to the patient.

With Hetastarch, in higher dosages (greater han 20 mL/kg/24h), renal impairment becomes an issue as well as an indeterminate half life.

I have actually heard at least one physician adamantly state that Hetastarch “stays with you for life”. I felt that was extreme- but it certainly made me think about it.


Voluven

  • 6% Hydroxyethyl Starch 130/0.4 in 0.9% sodium chloride injection
  • Is described by the manufacturer (Hospira) as:

“A nonhuman-derived colloid designed for the treatment and prevention of hypovolemia.”

Dosing Regimen (Hospira):

  • May be used up to 50 mL/kg of body weight per day (equivalent to 3,500 mL for a 70 kg patient)
  • Maintains effective blood volume expansion for up to 6 hours
  • Voluven can be administered repetitively over several days without significant plasma accumulation

Impact

In a study performed… (To review the study click here)

“The blood transfusion results discussed are consistent with the finding that factor VIII concentration and PTT were significantly less compromised by Voluven® than by HAES-steril® in the early postoperative phase.

These two coagulation variables are relevant for the evaluation of any new HES type, as it is known that higher substituted and higher molecular weight HES types lead to a prolonged PTT and a lower postoperative increase in factor VIII (6,8,22).

Postoperative increases in factor VIII, von Willebrand factor, and ristocetin cofactor are part of the physiologic acute phase reaction to surgical stress (23–25). Large and highly substituted HES molecules (hetastarch, HES 450.000/0.7) attenuate this physiologic response as compared with human albumin (24) or crystalloids (25), although the mechanism is not known (3,10).

Similarly, in our study the control HES specification significantly attenuated the factor VIII response as compared with Voluven®. Very similar results were obtained in previous clinical studies with Voluven® (15,16). The reduced influence of Voluven® on coagulation was also shown in an in vitro study “(17).

Comparison to Hetastarch

“We conclude that in large-blood–loss surgery, Voluven® may have a favorable coagulation profile and may lead to less homologous blood consumption compared with HAES-steril® (pentastarch), while the efficacy of both solutions in restoring plasma volume is equivalent. Nevertheless, further studies are required to show whether Voluven® can safely be used at larger dosages than currently recommended.”

Synthetic Versus … ?

Click the above image to view a very good article by Gerard J Myers:

An Excerpt:

“If your patient receives 500 mls of Voluven during induction, 500 mls in the prime, 500 mls during the surgery and another 500 mls during the first 24 hours post op … that patient has been hemodiluted by 4 liters or more within the first 24 hours of surgery … only from the colloid additions!!
Excessive hemodilution is what leads to RBC transfusions, not prime volumes.

To summarize, reducing the incidence of RBC transfusions is by no means a simple matter of using an oxygenator that has 100 mls less prime volume than another.

So why are we experiencing large growth in synthetic colloid use and risking the chance of prion transmissions, analyphalactic reactions, increases in pruritis post infusion and massively increases in costs if there is not advantages in improved outcomes over crystalloids? “

Gerard J Myers

Halifax, Nova Scotia

Discussion

For perioperative volume therapy in infants and young children, human albumin has frequently been the colloid of choice.

Recently, HES 130/0.4 (6% hydroxyethyl starch, Voluven; Fresenius Kabi, Bad Homburg, Germany) was developed, which demonstrated improved pharmacokinetics and a favorable safety profile in adults compared with hydroxyethyl starch products with a less rapid metabolization.

(Package Insert)

References

  • HES 130/0.4 (Voluven) or human albumin in children younger than 2 yr undergoing non-cardiac surgery. A prospective, randomized, open label, multicentre trial.

Standl T, Lochbuehler H, Galli C, Reich A, Dietrich G, Hagemann H.Academic Hospital Solingen, Department of Anesthesia and Critical Care Medicine, Solingen, Hannover, Germany. standl@klinikumsolingen.de

  • Anesth Analg. 2001 Apr;92(4):855-62. Voluven, a lower substituted novel hydroxyethyl starch (HES 130/0.4), causes fewer effects on coagulation in major orthopedic surgery than HES 200/0.5.

Langeron O, Doelberg M, Ang ET, Bonnet F, Capdevila X, Coriat P.

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