What are the guidelines for using Hydroxyethyl starch (HES) 6% for volume expansion?

Guidelines for Using Hydroxyethyl Starch (HES) 6% for Volume Expansion

Hydroxyethyl starch (HES) 6% should not be used for volume expansion in patients at risk for acute kidney injury, especially in critically ill or septic patients, due to increased risk of mortality and renal replacement therapy requirement. 1

Patient Population Considerations

Contraindicated in:

• Critically ill adult patients, including those with sepsis 2
• Patients with severe liver disease 2
• Patients with known hypersensitivity to hydroxyethyl starch 2
• Patients with pre-existing coagulation or bleeding disorders 2
• Clinical conditions where volume overload is a potential problem 2
• Patients with pre-existing renal dysfunction 2

Limited Indications:

• Treatment of hypovolemia when plasma volume expansion is desired (non-critically ill) 2
• Adjunctive use in leukapheresis 2

Evidence-Based Recommendations

First-Line Fluid Therapy:

• Use isotonic crystalloids rather than colloids (including HES) for initial management of volume expansion 1
• Balanced crystalloids are preferred over 0.9% normal saline to reduce risk of hyperchloremic metabolic acidosis 1

Monitoring Requirements if HES is Used:

1. Monitor renal function continuously

   • Discontinue at first sign of renal injury 2
   • Continue monitoring renal function for at least 90 days post-administration 2

2. Monitor coagulation parameters

   • Discontinue at first sign of coagulopathy 2
   • Not recommended during cardiac bypass or immediately after 2

3. Monitor liver function 2

Risk Assessment

High-Risk Scenarios:

• Sepsis: Multiple studies show increased mortality and renal replacement therapy with HES use 1, 3
• Critically ill patients: 90-day mortality increased (RR 1.14 [95% CI 1.04-1.26]) 3
• Patients with decreased renal function: 7.6-fold increased risk of AKI 4

Potential Adverse Effects:

• Acute kidney injury (AKI) and need for renal replacement therapy 1, 3
• Coagulopathy and increased risk of bleeding 1, 2
• Increased red blood cell transfusion requirements 3
• Hypersensitivity reactions 2
• Metabolic acidosis 2

Alternative Volume Expanders

Preferred Alternatives:

• Balanced crystalloid solutions (e.g., Ringer's acetate) 1
• Consider albumin only in specific circumstances, not as routine replacement for crystalloids 1

Special Considerations

Trauma Patients:

• Crystalloids are recommended as first-line therapy even in trauma 1
• If HES is used, dosing should be within prescribed limits and using modern HES solutions (e.g., 130/0.4) 1

Surgical Patients:

• While some studies show no difference in mortality or AKI in surgical patients receiving HES 5, the absence of demonstrable benefit does not support routine use
• In thoracic surgery, crystalloid restriction (≤3 mL·kg·h) was not associated with increased AKI risk 4

Key Pitfalls to Avoid

• Exceeding maximum permissible dose of HES 1
• Using older HES solutions (e.g., 200/0.5) which have worse safety profiles 1
• Continuing HES after signs of renal dysfunction appear 2
• Assuming newer HES formulations are completely safe - caution is still warranted 1

In summary, current evidence strongly supports avoiding HES 6% for volume expansion in most clinical scenarios, with crystalloid solutions being the safer alternative for maintaining intravascular volume.