What is the recommended dose of Hydroxyethyl Starch (HES) in milliliters per kilogram body weight per day for resuscitation?

Hydroxyethyl Starch (HES) Dosing Recommendations for Resuscitation

Hydroxyethyl starch (HES) is not recommended for fluid resuscitation in critically ill patients, including those with sepsis, due to increased risk of mortality and renal replacement therapy. 1, 2

Current Evidence Against HES Use

• HES solutions are contraindicated in critically ill adult patients, including those with sepsis, due to increased risk of mortality and renal replacement therapy 1
• Multiple randomized controlled trials have demonstrated safety concerns with HES, including:
  • The 6S Trial showed increased mortality rates with 6% HES 130/0.42 fluid resuscitation compared to Ringer's acetate (51% vs. 43%, P=0.03) 3
  • The CHEST study found increased need for renal replacement therapy with HES compared to saline (7.0% vs. 5.8%, P=0.04) 4
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis patients 1

Recommended Alternative: Crystalloid Solutions

• Crystalloids are recommended as the initial fluid of choice in resuscitation of patients with severe sepsis and septic shock (Grade 1B recommendation) 2
• An initial fluid challenge of at least 30 mL/kg of crystalloids is recommended for patients with sepsis-induced tissue hypoperfusion (Grade 1C) 2, 5
• Fluid administration should continue as long as there is hemodynamic improvement based on dynamic or static variables 2, 5

HES Dosing (If Used Despite Contraindications)

If HES must be used in specific circumstances where benefits might outweigh risks (which is rare):

• According to the FDA label, the typical dosage for adults is 500 to 1000 mL 6
• Doses exceeding 1500 mL per day for a 70 kg patient (approximately 20 mL/kg body weight) are usually not required 6
• The maximum daily dose should not exceed 50 mL/kg 6

Important Safety Considerations

• HES is associated with:
  • Increased risk of mortality in sepsis patients 3
  • Higher rates of renal replacement therapy 7, 4
  • Increased risk of bleeding complications 3
  • Tissue storage and pruritus 8
• Additional contraindications include:
  • Severe liver disease 1
  • Pre-existing coagulation or bleeding disorders 1
  • Conditions where volume overload is problematic (congestive heart failure, renal disease) 1

Clinical Implications

• The common belief that 3-4 times more crystalloid than colloid volume is needed for similar hemodynamic effects is overestimated; studies show a lower ratio of approximately 1.8:1 8
• Small surgical studies with HES were not designed to detect important safety outcomes due to inadequate sample sizes, inappropriate control fluids, and short observation periods 8
• For patients requiring substantial amounts of crystalloids, albumin may be considered in fluid resuscitation of severe sepsis and septic shock (Grade 2C) 2