What is the role of colloids, such as hydroxyethyl starch (HES) solutions, in managing significant bleeding?

Role of Colloids in Managing Significant Bleeding

Crystalloids should be used as first-line fluid therapy in significant bleeding, while colloids like hydroxyethyl starch (HES) should be avoided due to increased risks of renal failure, coagulopathy, and no proven mortality benefit compared to crystalloids. 1

Initial Fluid Resuscitation Approach

• Crystalloid solutions should be administered initially to treat hypotensive bleeding patients 1
• Balanced crystalloids (such as Ringer's acetate) are preferred over 0.9% NaCl to reduce mortality and adverse renal events 1
• Hypotonic solutions like Ringer's lactate should be avoided in patients with traumatic brain injury to prevent fluid shift into damaged cerebral tissue 1
• A restrictive volume strategy using crystalloids is generally accepted for the initial phase of traumatic hemorrhagic shock 1

Concerns with Hydroxyethyl Starch (HES) Use

• HES solutions are associated with:

  • Increased risk of renal failure and need for renal replacement therapy 1, 2, 3
  • Coagulopathy and increased bleeding risk 2, 4
  • Tissue storage and accumulation with repeated use 2, 5
  • Potential increased mortality in patients with severe sepsis 5

• FDA warnings highlight that HES can cause:

  • Significant clinical bleeding when used repeatedly 2
  • Intracranial bleeding resulting in death has been reported 2
  • Alterations in coagulation factors, particularly Factor VIII inhibition 2

Limited Role of Colloids in Bleeding Management

• Colloids may be considered only when:

  • Bleeding is excessive 1
  • Crystalloids in combination with vasopressors are unable to maintain basic tissue perfusion 1
  • Used within prescribed limits for each solution 1

• While colloids can result in lower fluid requirements than crystalloids (ratio of 1.5:1), this volume advantage does not translate to improved mortality or morbidity outcomes 1

• If colloids are used, modern HES solutions (lower molecular weight and lower substitution) may have fewer side effects on coagulation than older formulations, but safety concerns remain 6, 4

Special Considerations

• The concept of permissive hypotension (restrictive fluid resuscitation) is contraindicated in:

  • Traumatic brain injury and spinal injuries 1
  • Elderly patients 1
  • Patients with chronic arterial hypertension 1

• If erythrocyte transfusion becomes necessary during significant bleeding, target hemoglobin should be 70-90 g/L 1

• When using HES products, monitor:

  • Renal function 2, 3
  • Coagulation parameters (platelet count, prothrombin time, partial thromboplastin time) 2
  • Liver function 2

Current Best Practice

• For initial resuscitation in significant bleeding, use crystalloids rather than colloids 1
• If high ratios of FFP:RBC cannot be administered to trauma patients, resuscitation with at least 1 L crystalloid per unit RBC is associated with reduced overall mortality 1, 7
• The most recent evidence does not support the routine use of colloids like HES in clinical practice for managing significant bleeding 1, 5, 3