What is the maximum dose of hydroxyethyl starch (HES) for a typical adult patient?

Maximum Dose of Hydroxyethyl Starch

The FDA-approved maximum dose of hydroxyethyl starch (HES) for acute plasma volume expansion is 1500 mL per day for a typical 70 kg patient (approximately 20 mL/kg body weight), though doses up to 50 mL/kg daily have been used in severe hemorrhagic situations. 1

FDA-Approved Dosing Parameters

For acute plasma volume expansion:

• Standard dose range: 500-1000 mL 1
• Maximum recommended daily dose: 1500 mL for a 70 kg patient (~20 mL/kg) 1
• Higher doses have been reported in postoperative and trauma patients with severe blood loss, but these exceed standard recommendations 1

For leukapheresis procedures:

• 250-700 mL administered at a ratio of 1:8 to 1:13 to venous whole blood 1

Critical Safety Considerations

HES should generally not be used in modern clinical practice due to significant safety concerns that outweigh any theoretical benefits:

Contraindications and High-Risk Populations

• Absolutely contraindicated in critically ill patients, including those with sepsis, due to increased mortality and need for renal replacement therapy 2
• Contraindicated in severe liver disease, congestive heart failure, renal disease, and pre-existing coagulation disorders 2
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis 2

Dose-Related Complications

When doses exceed 1500 mL per day, the following complications become increasingly likely:

• Renal failure: HES is associated with acute kidney injury and increased need for renal replacement therapy, with the FLASH study showing significantly more renal failure in the HES group (RR 1.34, p=0.05) 3
• Coagulopathy: Doses above 1500 mL cause bleeding complications through decreased factor VIII/von Willebrand factor, platelet dysfunction, and incorporation into fibrin clots 4, 5
• Pruritus: Can occur even with small doses and presents as severe, protracted, treatment-refractory itching 6
• Anaphylactoid reactions: 4.5 times more frequent than with albumin 6

Current Clinical Recommendations

French health authorities (HAS) since 2014 restrict HES to second-line treatment only for blood loss when crystalloids are deemed insufficient 3

Crystalloids are strongly preferred over HES:

• Balanced crystalloids should be used as first-line therapy for hemorrhagic shock to reduce mortality and adverse renal events 3
• No mortality benefit has been demonstrated with HES compared to crystalloids in hemorrhagic shock, trauma, or major surgery 3, 7
• HES use during major non-cardiovascular surgery is associated with significantly higher hemorrhagic risk and transfusion requirements 3

Common Pitfall to Avoid

The belief that 3-4 times more crystalloid than colloid is needed is incorrect. Studies show the actual crystalloid-to-colloid ratio is approximately 1.8:1, meaning the fluid-sparing effect of HES is substantially overestimated 8. This misconception should not drive clinical decision-making toward HES use.

Practical Algorithm

If HES must be used despite safety concerns:

1. Limit to hemorrhagic shock scenarios where crystalloids have proven insufficient 3
2. Do not exceed 20 mL/kg (1500 mL for 70 kg patient) per day 1
3. Use modern HES 130/0.4 formulation if available 3
4. Monitor renal function closely (serum creatinine, eGFR) 9
5. Assess coagulation parameters if doses approach or exceed 1500 mL 4
6. Duration should not exceed 24 hours 1

However, the strongest recommendation is to avoid HES entirely and use balanced crystalloids for volume resuscitation in virtually all clinical scenarios. 3, 10, 7, 2