When to switch from normal saline to Volulyte (hydroxyethyl starch) for fluid resuscitation?

Do Not Switch to Volulyte (Hydroxyethyl Starch) After 1500mL of Normal Saline

You should not switch to Volulyte (hydroxyethyl starch) after administering 1500mL of normal saline—instead, continue with crystalloid solutions, preferably switching to a balanced crystalloid like lactated Ringer's or Plasma-Lyte rather than continuing normal saline. 1, 2

Why Hydroxyethyl Starch Should Be Avoided

Strong Guideline Recommendations Against HES

• The 2012 Surviving Sepsis Campaign guidelines explicitly recommend against the use of hydroxyethyl starches for fluid resuscitation in severe sepsis and septic shock (Grade 1B recommendation) 1
• The 2022 French guidelines state it is probably not recommended to use colloid solutions (including HES) in comparison with crystalloids to reduce mortality and/or renal replacement therapy requirement (Grade 2-) 1
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis patients, due to increased risk of mortality and renal failure 2

Evidence of Harm from HES

• The 6S Trial demonstrated increased mortality with 6% HES 130/0.42 compared to Ringer's acetate in septic patients (51% vs 43%, P = 0.03) 1
• The CHEST study showed HES was associated with increased need for renal replacement therapy (RR 1.21; 95% CI 1.00-1.45; P = 0.04) compared to saline 3
• HES causes more adverse events including pruritus, skin rash, coagulopathy, and tissue storage compared to crystalloids 3, 4
• The FLASH study found renal failure was significantly more frequent in the HES group during high-risk abdominal surgery 1

What You Should Do Instead

Switch to Balanced Crystalloids

• After 1500mL of normal saline, switch to balanced crystalloids (lactated Ringer's or Plasma-Lyte) rather than continuing normal saline or using HES 5, 6
• Balanced crystalloids should be preferred over normal saline to reduce the risk of hyperchloremic metabolic acidosis and acute kidney injury 6, 7
• Continue crystalloid administration as long as there is hemodynamic improvement based on dynamic measures (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate, urine output) 1, 6

Total Crystalloid Volume Recommendations

• Administer at least 30 mL/kg of crystalloids within the first 3 hours for sepsis-induced tissue hypoperfusion 1, 5, 6
• More rapid administration and greater amounts may be needed in some patients based on ongoing hemodynamic assessment 1
• The historical concern that crystalloids require 3-4 times the volume of colloids is overstated—actual volume ratios are closer to 1.4:1 1, 7

When to Consider Albumin (Not HES)

• If the patient requires substantial amounts of crystalloids and remains hemodynamically unstable, albumin may be considered as an alternative to HES (Grade 2C recommendation) 1, 2
• Albumin is safer than synthetic colloids like HES, though more expensive 1, 4

Critical Pitfalls to Avoid

• Do not use HES based on outdated beliefs that colloids are more efficient volume expanders—the mortality and renal risks outweigh any theoretical volume expansion benefit 1, 2
• Do not continue normal saline indefinitely—switch to balanced crystalloids after initial resuscitation to avoid hyperchloremic acidosis and AKI 6, 7
• Do not delay adequate fluid resuscitation out of concern for fluid overload—monitor for signs of adequate perfusion and stop fluids when hemodynamic improvement plateaus 5, 6