What is the recommended dosing and administration protocol for hetastarch in a patient with impaired renal function and a history of allergic reactions?

Hetastarch Ordering Protocol

Do not use hetastarch in patients with impaired renal function or history of allergic reactions—this drug is contraindicated in these populations and associated with significantly increased mortality and acute kidney injury. 1, 2

Critical Contraindications

• Renal impairment: Hetastarch is eliminated primarily through urine and requires dose adjustment in severe renal impairment, but given the strong association with acute kidney injury (13% incidence, relative risk 1.73), it should be avoided entirely in patients with baseline renal dysfunction 3, 2
• Allergic history: The FDA label does not provide guidance for patients with prior allergic reactions, making this a relative contraindication where alternative volume expanders should be strongly preferred 1

Standard Ordering Protocol (For Patients WITHOUT Contraindications)

Initial Order Components

Order hetastarch 6% (HEXTEND) 500-1000 mL IV infusion 1, 3

• Route: Intravenous infusion only 1
• Rate: Administer over 5-7 minutes for rapid volume expansion, or titrate based on hemodynamic response 4
• Maximum daily dose: Do not exceed 1500 mL per day (approximately 20 mL/kg for a 70 kg patient) 1, 3

Essential Concurrent Orders

• Baseline labs: Obtain hematocrit, coagulation studies (PT/PTT), serum creatinine, and amylase before administration 3
• Monitoring parameters:
  • Vital signs every 15 minutes during infusion 5
  • Pulmonary artery wedge pressure if available (target 15 mm Hg) 5
  • Hematocrit every 5 minutes for first 30 minutes to assess volume expansion 4
  • Renal function monitoring daily during therapy 2

Critical Safety Orders

• Separate IV line: Do not administer through same line as blood products due to calcium content causing coagulation 1
• Pump discontinuation protocol: Ensure pumping device is discontinued before container runs dry to prevent air embolism 1
• Single-dose use: Discard unused portion—contains no bacteriostat 1

Dosing Adjustments for Special Populations

Severe Renal Impairment

Recommendation: Use alternative volume expander (crystalloid or albumin) rather than attempting dose adjustment, given the 1.70 odds ratio for renal dysfunction and 1.96 odds ratio for mortality associated with hetastarch use 2

Trauma Patients

Avoid hetastarch entirely—independent association with mortality (21% vs 11%, relative risk 1.84) and acute kidney injury in this population 2

Expected Hemodynamic Response

• Peak volume expansion: Expect 1123 mL intravascular volume expansion from 1000 mL hetastarch (occurring 5 minutes post-infusion), compared to only 630 mL with equivalent crystalloid 4
• Cardiac index improvement: Anticipate increase from approximately 2.9 to 3.5 L/min/m² 6
• Duration: Hetastarch provides superior and more sustained volume expansion compared to crystalloid for acute resuscitation 4, 5

Common Pitfalls to Avoid

• Exceeding maximum dose: Doses >1500 mL/day cause dose-related hematologic abnormalities and coagulation defects 3
• Ignoring renal function: Major route of elimination is urinary; failure to assess baseline renal function before administration increases risk of acute kidney injury 3, 2
• Co-administration with blood: Calcium content causes coagulation when mixed with blood products 1
• Using in septic shock: While hetastarch has been studied in sepsis, newer evidence from the 6S trial (referenced in guideline context) shows increased mortality and renal replacement therapy needs with HES 130/0.42 in severe sepsis 7

Alternative Volume Expanders (Preferred in High-Risk Patients)

• Isotonic crystalloids: Require 2-4 times the volume but associated with lower incidence of pulmonary edema (12.5% vs 22% with hetastarch) and no renal toxicity 7, 5
• 5% Albumin: Performs equivalently to hetastarch for hemodynamic endpoints without the renal toxicity risk, though substantially more expensive 3, 5