What is the recommended dose for Hydroxyethyl Starch (HES)?

Recommended Dosing for Hydroxyethyl Starch (HES)

HES is not recommended for use in critically ill patients, including those with sepsis, due to increased risk of mortality and renal replacement therapy. 1

Safety Concerns and Contraindications

• HES is contraindicated in critically ill adult patients, including those with sepsis, due to increased risk of mortality and renal replacement therapy 1
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis patients 2, 1
• Additional contraindications include severe liver disease, pre-existing coagulation disorders, and clinical conditions where volume overload is a potential problem 1
• Multiple studies have shown increased risk of acute kidney injury and mortality with HES use in septic patients 2, 3

Current Recommendations for Fluid Resuscitation

• Crystalloids are recommended as the initial fluid of choice in resuscitation of patients with severe sepsis and septic shock 1
• Balanced crystalloids should be used in preference to 0.9% normal saline for resuscitation 2, 1
• For emergency situations, the use of HES solutions is not recommended due to the increased risk of kidney failure and mortality 1

If HES Must Be Used (Limited Indications)

• If HES is employed, a modern HES solution (130/0.4) should be used 2
• Dosing should be within the prescribed limits, which is a maximum of 50 mL/kg per day 2, 1
• The typical cumulative dose used in studies was around 2465 mL (range 328 to 6229 mL), corresponding to approximately 35 mL/kg in a 70-kg patient 4
• Low cumulative doses (median 1,450 mL) have shown no association with renal adverse events in some specific patient populations such as those with acute ischemic stroke 5

HES Formulations and Considerations

• HES is classified according to its molecular weight (MW) into high MW (450-480 kDa), medium MW (200 kDa), and low MW (70 kDa) preparations 6
• The rate of metabolization depends mainly on the degree of hydroxyethyl substitution (ranging from 0.4 to 0.7) 6
• Modern HES formulations (130/0.4) are designed to have improved safety profiles compared to older formulations 1, 6
• One small RCT showed that HES (130/0.4) provided better lactate clearance and less renal injury than saline in penetrating trauma patients, but this benefit was not observed in blunt trauma patients 2, 7

Alternative Fluid Options

• Balanced crystalloid solutions are preferred for most resuscitation scenarios 1, 8
• For initial resuscitation, balanced isotonic crystalloids should be administered at 10-20 ml/kg 8
• 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 4
• For patients requiring substantial amounts of crystalloids, albumin may be considered in specific situations 1

Monitoring and Precautions

• If HES is used, closely monitor renal function and coagulation parameters 1, 3
• Avoid excessive fluid administration, which can lead to respiratory failure and complications from volume overload 8
• The infusion rate should be more conservative in patients with heart failure or liver cirrhosis 8