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

Hydroxyethyl starch (HES) solutions have shown their efficiency for intravascular volume expansion. However, a safety recommendation limiting their use in adult patients has recently been made. The aim of this meta-analysis was to assess the efficacy and adverse effects of HES when administered intra-operatively to paediatric patients. A search was performed for randomised controlled trials (RCTs) published before December 2016 involving paediatric patients who received 6% low molecular weight HES. Reviewers extracted valid data, including peri-operative total fluid intakes, mortality, renal function, coagulation tests, blood loss and length of hospital and ICU stay. All 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. 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. Finally, all results were graded as very low quality of evidence. 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.