Dextran is a complex branched polysaccharide (a type of carbohydrate) composed of glucose molecules. It is produced by certain bacteria, such as Leuconostoc mesenteroides and Streptococcus mutans, through the fermentation of sucrose or other sugar sources. Dextran molecules can vary significantly in size, from a few thousand to several million glucose units long.

Dextran is available as Dextran 40 and Dextran 70 depending on the molecular mass. It is used in volume expansion in hypotensive patients and as a plasma expander in patients with capillary leak syndromes.

Dextran Uses:

• When blood or blood products are unavailable, it is advised as a blood volume expander is used to treat shock or imminent shock.
• During cardiopulmonary bypass, it is also employed as a priming fluid in pump oxygenators.

Dextran Dose in Adults

Dextran Dose for Volume expansion or the management of shock:

• When someone is severely dehydrated or in shock, doctors might use a solution called Dextran to help expand their blood volume.
• They inject it into a vein (IV).
• The typical dose of Dextran 40 is 500 to 1000 milliliters, which is about 10 milliliters for every kilogram the person weighs.
• They try to give it as quickly as possible.
• Doctors usually don't give more than 20 milliliters per kilogram in a day for the first 24 hours, and after that, they limit it to 10 milliliters per kilogram each day.
• They shouldn't continue this therapy for more than 5 days.

Dose in the Pump prime:

• When Dextran 40 is used to prime the pump oxygenator during medical procedures like heart surgeries, the dose depends on the size of the pump.
• Typically, it's given at a rate of 10 to 20 milliliters for every kilogram the person weighs, or 1 to 2 grams per kilogram.
• The maximum total dose usually doesn't exceed 20 milliliters per kilogram, or 2 grams per kilogram.

Dextran Dose in Children

The patient's fluid condition must be taken into account while determining the appropriate dose and infusion rate.

Dextran Dose in the management of Shock:

• For infants, children, and adolescents, the initial dose is typically 20 milliliters per kilogram of body weight, given intravenously as a bolus over at least 5 minutes.
• This initial dose can be repeated as necessary based on the patient's response to treatment.
• It's important to follow guidelines and consider individual patient factors when determining the appropriate fluid therapy.

Dextran Dose for Volume expansion (nonshock-like conditions):

Infants:

• Intravenously infuse 5 milliliters per kilogram of body weight as rapidly as necessary. The maximum daily dose is 20 milliliters per kilogram for the first 24 hours, then reduced to 10 milliliters per kilogram per day. This therapy should not continue beyond 5 days.

Children and Adolescents weighing less than 50 kilograms:

• Intravenously infuse 10 milliliters per kilogram of body weight as rapidly as necessary.
• The maximum daily dose is 20 milliliters per kilogram for the first 24 hours, then reduced to 10 milliliters per kilogram per day.
• This therapy should not continue beyond 5 days.

Adolescents weighing 50 kilograms or more:

• Intravenously infuse 500 to 1,000 milliliters (which is roughly 10 milliliters per kilogram) as rapidly as necessary.
• The maximum daily dose is 20 milliliters per kilogram for the first 24 hours, then reduced to 10 milliliters per kilogram per day.
• This therapy should not continue beyond 5 days.

Dose for priming the pump: IV:

When using Dextran for pump priming during medical procedures like heart surgeries, the dose depends on the age group:

Infants:

• Intravenously administer 5 milliliters per kilogram of body weight.
• The usual maximum total dose is 20 milliliters per kilogram per day.

Children:

• Intravenously administer 10 milliliters per kilogram of body weight.
• The usual maximum total dose is 20 milliliters per kilogram per day.

Adolescents:

• Intravenously administer 10 to 20 milliliters per kilogram of body weight.
• The usual maximum total dose is 20 milliliters per kilogram per day.

The specific dose may vary based on the volume of the pump oxygenator and individual patient needs. It's important to follow these guidelines and not exceed the recommended maximum total dose per day.

Dextran Pregnancy Risk Category: C

• No studies on how this medicine affects animals when they reproduce have been done.

Use during breastfeeding:

• It's unclear if dextran passes into breast milk.
• The manufacturer advises being cautious when giving dextran to nursing mothers.

Dose in Kidney Disease:

• Use with extreme caution.

Dose in Liver disease:

• Use with extreme caution.

Side effects of Dextran:

• Dermatologic:
  • Urticaria
• Cardiovascular:
  • Chest tightness
  • Hypotension
• Gastrointestinal:
  • Nausea
  • Vomiting
• Hepatic:
  • Abnormal liver function tests
• Hematologic & oncologic:
  • Wound hemorrhage (dose-related)
  • Prolonged bleeding time (dose-related)
  • Wound hematoma (dose-related)
• Hypersensitivity:
  • Anaphylactoid reaction
• Respiratory:
  • Pulmonary edema (dose-related)
  • Wheezing  
• Renal:
  • Acute renal failure

Contraindications to Dextran:

• Dextran should not be used if someone has a severe allergic reaction to it or any part of the product.
• It's also not suitable for individuals with significant blood clotting problems, such as low platelet count or low fibrinogen levels, whether from medications like heparin or warfarin or other causes.
• Additionally, it's not recommended for those with severe heart failure or kidney disease leading to very low urine output or no urine production at all.

Warnings and precautions

Fluid overload:

• Giving dextran can lead to too much fluid in the body, known as fluid overload.
• It's essential to be cautious when using it in patients who might be at risk for having too much blood volume, such as very young or elderly patients, or those with heart failure.

Hematologic:

• Using large amounts of dextran, especially doses exceeding 1000 milliliters, can lead to lower hemoglobin levels and overly diluted plasma proteins due to increased blood volume.
• This may result in a temporary increase in bleeding time or a higher risk of bleeding.
• It's important to be careful to prevent the hematocrit level from dropping below 30%.

Hypersensitivity

• Severe and even fatal allergic reactions, called anaphylactoid reactions, have been reported with dextran use.
• If signs of hypersensitivity occur, it's crucial to stop using dextran immediately and provide appropriate treatment.

Failure of the renal system:

• Renal failure has been reported in some cases with the use of dextran.
• It's important to closely monitor the fluid status of patients receiving dextran, including their urine output, to help prevent renal complications.

Heart failure:

• Dextran should be used cautiously in patients with heart failure, as it can contribute to fluid overload.
• Close monitoring for signs of excess fluid accumulation is essential in these patients.

Hemorrhage:

• Dextran should be used cautiously in patients who are experiencing active bleeding, as it may further increase the risk of hemorrhage.
• Close monitoring is important in such cases to manage any potential complications.

Renal impairment

• Dextran should be used cautiously in patients with renal impairment, as it can affect their fluid balance.
• Close monitoring of fluid status, including urine output, is crucial in these patients.
• Overly high doses may worsen renal function, especially in those with advanced kidney disease.
• It's contraindicated in severe cases of low urine output (oliguria) or no urine production (anuria).

Thrombocytopenia:

• Dextran should be used cautiously in patients with thrombocytopenia, a condition characterized by low platelet counts.
• Larger doses, particularly exceeding 1000 milliliters, may affect platelet function and temporarily prolong bleeding time.
• Patients should be closely observed for signs of bleeding when receiving dextran.

Dextran: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitoring parameters:

Vital Signs:

• Blood pressure
• Heart rate
• Central venous pressure (CVP)
• Right atrial pressure (RAP)
• Mean arterial pressure (MAP)
• Capillary refill time

Advanced Monitoring (if available):

• Cardiac index
• Pulmonary capillary wedge pressure (PCWP)
• Systemic vascular resistance (SVR)
• Pulmonary vascular resistance (PVR)

Laboratory Parameters:

• Hemoglobin and hematocrit levels
• Electrolyte levels
• Serum protein levels
• Coagulation parameters
• Renal function tests
• Urine output
• Acid-base balance

Close Observation:

• Monitor patients closely, especially during the first minute of infusion.
• Have alternative methods ready to maintain circulation in case of an anaphylactoid reaction to dextran therapy.

How to administer Dextran?

• Crystalline Precipitate:
  • Do not use if there's a crystalline precipitate formed in the solution.
• Infusion Method:
  • Administer via IV infusion only, using an infusion pump or pressure infusion device.
• Volume Expansion/Shock:
  • Initial volume for volume expansion or shock may be infused as rapidly as possible.
• Anaphylactic Reaction Monitoring:
  • Monitor closely for signs of anaphylactic reaction during infusion.
  • Have epinephrine and resuscitative equipment readily available in case of such a reaction.

Mechanism of action of Dextran:

Dextran works by expanding plasma volume due to its highly colloidal starch structure.

Duration of Effect:

• The plasma expanding effect of dextran typically lasts for 3 to 4 hours after administration.

Excretion:

• Dextran is primarily excreted in the urine, with around 75% of the administered dose eliminated within 24 hours.

 International Brand Names of Dextran:

• LMD in D5W
• LMD in NaCl
• Dekstran 40000
• Dekstran 70000
• Deltadex
• Dextran 40
• Dextran 40 Injection
• Dextran 70
• Dextran 70 Injection
• Gentran
• Gentran 40
• Gentran 70
• LM Dextran
• Longasteril 40°
• Macrodex 10%
• Plander
• Plasmex
• Rheomacrodex
• Soludeks 40
• Soludeks 70

Dextran Brand Names in Pakistan: