What is the recommended clinical administration of Hydroxyethyl Starch (HES) for volume expansion?

Clinical Administration of Hydroxyethyl Starch (HES)

Hydroxyethyl starch (HES) is not recommended for volume expansion in critically ill patients, particularly those with sepsis, due to increased risks of mortality and renal replacement therapy. 1, 2

Current Recommendations Against HES Use

• HES is contraindicated in critically ill adult patients, including those with sepsis, due to increased risk of mortality and renal replacement therapy 2
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis patients 1, 2
• Crystalloids are recommended as the first-choice fluid for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock 1
• HES should not be routinely used for intraoperative fluid administration 1

Specific Contraindications for HES

• Sepsis or septic shock 1, 2
• Pre-existing renal dysfunction 2, 3
• Severe liver disease 2
• Coagulation or bleeding disorders 2
• Congestive heart failure or conditions where volume overload is a concern 2

Limited Clinical Applications

In the rare circumstances where HES might still be considered (noting the significant safety concerns):

• HES should only be used as a second-line treatment in the event of blood loss when crystalloids are deemed insufficient 1
• If administered, HES should be used within prescribed limits (maximum daily dose of 50 ml/kg) 1, 4
• Modern HES solutions (130/0.4) should be used rather than older formulations 1
• Administration should be discontinued at the first sign of renal dysfunction 3

Safety Concerns

• Multiple large randomized controlled trials have demonstrated increased risk of:

  • Mortality 1, 2, 3
  • Renal replacement therapy requirement 1, 3
  • Acute kidney injury 3
  • Coagulopathy and increased bleeding risk 1

• The CHEST study reported increased incidence of renal replacement therapy in the HES group compared to isotonic crystalloids 2

• A systematic review of HES 130/0.4 found that most studies were not designed to adequately assess safety outcomes 4

Recommended Alternatives

• Balanced crystalloids are the preferred initial fluid for resuscitation in most clinical scenarios 1, 2
• For patients requiring substantial amounts of crystalloids, albumin may be considered in the fluid resuscitation of severe sepsis and septic shock 1
• When considering fluid resuscitation, aim for a mildly positive fluid balance (+1-2 L) by the end of the case to protect kidney function 1

Special Considerations

• In specific procedures like leukocytapheresis, low-dose HES has not been associated with the adverse events seen when used as a volume expander 5, 6
• The common belief that 3-4 times more crystalloid than colloid volume is needed to achieve similar hemodynamic effects is overestimated; the actual ratio is closer to 1.8:1 4

HES administration carries significant risks that generally outweigh potential benefits in most clinical scenarios. Current evidence and guidelines strongly favor crystalloids as the first-line fluid therapy for volume expansion.