Original Article| Volume 37, ISSUE 3, P399-406, March 2023

Perioperative Gelatin Use Is Associated With Increased Complication Rates and Does Not Prevent Postoperative Fluid Overload in Patients Undergoing Elective Cardiac Surgery

Published:December 03, 2022DOI:


      The benefit of using gelatin solution in cardiac surgery is still controversial. Previous data suggested adverse interactions of gelatin infusion with acute kidney injury (AKI) or coagulopathy. The purpose of this study was to evaluate the association between perioperative gelatin use and fluid overload (FO), hemodynamic stability, and outcomes compared to crystalloid-based fluid management.


      A retrospective study design.


      At a single-center tertiary university setting.


      Propensity score-matched cohort study of 191 pairs of patients scheduled for cardiac surgery.


      Patients received either gelatin + crystalloid or pure crystalloid-based perioperative fluid management. The primary outcomes were the frequency of FO and hemodynamic stability defined by the vasoactive-inotropic score. Postoperative complications and 3-year survival were analyzed also.

      Measurements and Main Results

      Patients who received gelatin experienced more frequent postoperative FO than controls (11.0% v 3.1%, p = 0.006) despite comparable hemodynamic stability in both groups. Gelatin administration was linked with a higher rate of postoperative complications, including blood loss, AKI, and new-onset postoperative atrial fibrillation. Use of gelatin infusion resulted in an adjusted odds ratio of 1.982 (95% CI 1.051-3.736, p = 0.035) for developing early postoperative AKI. This study confirmed a dose-dependent relationship between gelatin infusion and AKI. Thirty-day mortality and 3-year survival were similar in the groups.


      Gelatin administration versus crystalloid fluid management showed a significant association with a higher rate of FO and an increased risk for early postoperative AKI in a dose-dependent manner.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Parke RL
        • McGuinness SP
        • McCarthy LW
        • et al.
        Intravenous fluid use after cardiac surgery: A multicentre, prospective, observational study.
        Crit Care Resusc. 2014; 16: 164-169
        • Aronson S
        • Nisbet P
        • Bunke M.
        Fluid resuscitation practices in cardiac surgery patients in the USA: A survey of health care providers.
        Perioper Med. 2017; 6: 15
        • Romagnoli S
        • Rizza A
        • Ricci Z.
        Fluid status assessment and management during the perioperative phase in adult cardiac surgery patients.
        J Cardiothorac Vasc Anesth. 2016; 30: 1076-1084
        • Schramko AA
        • Suojaranta-Ylinen RT
        • Niemi TT
        • et al.
        Comparison of the effect of 6% hydroxyethyl starch and gelatine on cardiac and stroke volume index: A randomized, controlled trial after cardiac surgery.
        Perfusion. 2010; 25: 283-291
        • Protsyk V
        • Rasmussen BS
        • Ender J
        • et al.
        Fluid management in cardiac surgery: Results of a survey in European cardiac anesthesia departments.
        J Cardiothorac Vasc Anesth. 2017; 31: 1624-1629
        • Zarychanski R
        • Abou-Setta AM
        • Turgeon AF
        • et al.
        Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: A systematic review and meta-analysis.
        JAMA. 2013; 309: 678-688
        • Myburgh JA
        • Finfer S
        • Bellomo R
        • et al.
        Hydroxyethyl starch or saline for fluid resuscitation in intensive care.
        N Engl J Med. 2012; 367: 1901-1911
        • Saw MM
        • Chandler B
        • Ho KM.
        Benefits and risks of using gelatin solution as a plasma expander for perioperative and critically ill patients: A meta-analysis.
        Anaesth Intensive Care. 2012; 40: 17-32
        • Bayer O
        • Schwarzkopf D
        • Torsten Doenst T
        • et al.
        Perioperative fluid therapy with tetrastarch and gelatin in cardiac surgery-a prospective sequential analysis*.
        Crit Care Med. 2013; 41: 2532-2542
        • Moeller C
        • Fleischmann C
        • Thomas-Rueddel D
        • et al.
        How safe is gelatin? A systematic review and meta-analysis of gelatin-containing plasma expanders vs crystalloids and albumin.
        J Crit Care. 2016; 35: 75-83
        • Reddy S
        • McGuinness S
        • Young P
        • et al.
        Choice of fluid therapy and bleeding risk after cardiac surgery.
        J Cardiothorac Vasc Anesth. 2016; 30: 1094-1103
        • Balakumar V
        • Murugan R
        • Kellum JA
        • et al.
        Both positive and negative fluid balance may be associated with reduced long-term survival in the critically Ill.
        Crit Care Med. 2017; 45: e749-e757
        • Yamazaki Y
        • Oba K
        • Morimoto Y
        • et al.
        Vasoactive-inotropic score as a predictor of morbidity and mortality in adults after cardiac surgery with cardiopulmonary bypass.
        J Anesth. 2018; 32: 167-173
        • Khwaja A.
        KDIGO clinical practice guidelines for acute kidney injury.
        Nephron Clin Pract. 2012; 120: c179-c184
        • Austin PC.
        The use of propensity score methods with survival or time-to-event outcomes: Reporting measures of effect similar to those used in randomized experiments.
        Stat Med. 2014; 33: 1242-1258
        • Stein A
        • de Souza LV
        • Belettini CR
        • et al.
        Fluid overload and changes in serum creatinine after cardiac surgery: Predictors of mortality and longer intensive care stay. A prospective cohort study.
        Crit Care. 2012; 16: R99
        • Shen Y
        • Zhang W
        • Ying M
        • et al.
        Association between postoperative fluid balance and acute kidney injury in patients after cardiac surgery: A retrospective cohort study.
        J Crit Care. 2018; 44: 273-277
        • Verheij J
        • Van Lingen A
        • Beishuizen A
        • et al.
        Cardiac response is greater for colloid than saline fluid loading after cardiac or vascular surgery.
        Intensive Care Med. 2006; 32: 1030-1038
        • Smart L
        • Boyd C
        • Litton E
        • et al.
        A randomised controlled trial of succinylated gelatin (4%) fluid on urinary acute kidney injury biomarkers in cardiac surgical patients.
        Int Care Med Exp. 2021; 9: 14
        • Koponen T
        • Musialowicz T
        • Lahtinen P.
        Gelatin and the risk of acute kidney injury after cardiac surgery.
        Acta Anaesthesiol Scand. 2022; 66: 215-222
        • Evans PA
        • Glenn JR
        • Madira W
        • et al.
        Effects of gelatin-based resuscitation fluids on platelet aggregation.
        Br J Anaesth. 1998; 81: 198-202
        • Mardel SN
        • Saunders FM
        • Allen H
        • et al.
        Reduced quality of clot formation with gelatin-based plasma substitutes.
        Br J Anaesth. 1998; 80: 204-207
        • Schramko A
        • Suojaranta-Ylinen R
        • Niemi T
        • et al.
        Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: A prospective randomized trial.
        Br J Anaesth. 2010; 104: 691-697
        • Koponen T
        • Musialowicz T
        • Lahtinen P.
        Gelatin and the risk of bleeding after cardiac surgery.
        Acta Anaesthesiol Scand. 2020; 64: 1438-1445
        • Coakley M
        • Hall JE
        • Evans C
        • et al.
        Assessment of thrombin generation measured before and after cardiopulmonary bypass surgery and its association with postoperative bleeding.
        J Thromb Haemost. 2011; 9: 282-292
        • Gielen C
        • Dekkers O
        • Stijnen T
        • et al.
        The effects of pre- and postoperative fibrinogen levels on blood loss after cardiac surgery: A systematic review and meta-analysis.
        Interact Cardiovasc Thorac Surg. 2014; 18: 292-299
        • Wang Y
        • Bellomo R.
        Cardiac surgery-associated acute kidney injury: Risk factors, pathophysiology and treatment.
        Nat Rev Nephrol. 2017; 13: 697-711
        • Just IA
        • Alborzi F
        • Godde M
        • et al.
        Cardiac surgery-related acute kidney injury risk factors, clinical course, management suggestions.
        J Cardiothorac Vasc Anesth. 2022; 36: 444-451
        • Schick MA
        • Isbary TJ
        • Schlegel N
        • et al.
        The impact of crystalloid and colloid infusion on the kidney in rodent sepsis.
        Intensive Care Med. 2010; 36: 541-548
        • Simon TP
        • Schuerholz T
        • Hüter L
        • et al.
        Impairment of renal function using hyperoncotic colloids in a two hit model of shock: A prospective randomized study.
        Crit Care. 2012; 16: R16
        • Hinoue T
        • Nahara I
        • Yatabe T
        • et al.
        Hyperchloremia and postoperative acute kidney injury in adult cardiac patients: A propensity-matched cohort study.
        J Cardiothorac Vasc Anesth. 2022; 36: 1336-1342
        • Coulson T
        • Bailey M
        • Pilcher D
        • et al.
        Predicting acute kidney injury after cardiac surgery using a simpler model.
        J Cardiothorac Vasc Anesth. 2021; 35: 866-873
        • Heringlake M
        • Berggreen AE
        • Enno Reemts E
        • et al.
        Fluid therapy with gelatin may have deleterious effects on kidney function: An observational trial.
        J Cardiothorac Vasc Anesth. 2020; 34: 2674-2681
        • Kalus JS
        • Caron MF
        • White CM
        • et al.
        Impact of fluid balance on incidence of atrial fibrillation after cardiothoracic surgery.
        Am J Cardiol. 2004; 94: 1423-1425
        • Todorov H
        • Janssen I
        • Honndorf S
        • et al.
        Clinical significance and risk factors for new onset and recurring atrial fibrillation following cardiac surgery - a retrospective data analysis.
        BMC Anesthesiol. 2017; 17: 163
        • Schnaubelt S
        • Pilz A
        • Koller L
        • et al.
        The impact of volume substitution on post-operative atrial fibrillation.
        Eur J Clin Invest. 2021; 51: e13456