Effects of hydroxyethyl starch in critically ill patients.

we reported were in compliance with the Victoria DHS Guidelines for DES, which fall within the FDA guidelines, and therefore do not constitute ‘off-label’ use. With respect to the protocol developed in the Geelong Hospital, we assumed that the DES was a ‘high-risk lesion’ in the coronary circulation and devised a treatment regimen to reduce the risk of coronary occlusion while at the same time minimizing the risk of bleeding at the time of surgery. We are not sure what the view of ‘most surgeons’ with respect to antiplatelet agents is, but would add some data from our unpublished survey of 24 patients with DES presenting for a total of 43 non-cardiac surgery procedures at this institution. On 15 occasions clopidogrel was stopped, although aspirin was continued. Three patients suffered myocardial infarction due to in-stent thrombosis and two of the myocardial infarcts occurred before surgery. Of the 18 patients undergoing surgery while still on clopidogrel, the only patient to suffer excessive bleeding was transferred from a rural hospital and required two emergency laparotomies, after an episode of severe rectal bleeding. Our institutional guidelines now advise that patients undergoing superficial, ophthalmic, or minor surgery (including endoscopy without biopsy) should continue clopidogrel throughout the perioperative period. More complex surgery should be planned in consultation with a perioperative physician or cardiologist experienced in the management of these patients at the time of surgery.