For an adult postoperative patient with hypotension due to volume depletion after non‑septic surgery, normal renal function (eGFR ≥ 60 mL/min/1.73 m²) and no active coagulopathy, should I use 6 % hydroxyethyl starch (HES 130/0.4) and what dose is appropriate?

Hydroxyethyl Starch in Postoperative Hypotension

Primary Recommendation

Do not use 6% hydroxyethyl starch (HES 130/0.4) for postoperative hypotension—use balanced crystalloids (lactated Ringer's or Plasma-Lyte) as first-line therapy instead. 1

The most recent high-quality guidelines from the British Journal of Anaesthesia (2024) provide a strong recommendation against routine use of synthetic colloids including HES for intraoperative or postoperative fluid administration, based on high-quality evidence. 1

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Why HES Should Be Avoided

Renal Toxicity

• HES increases the risk of acute kidney injury even in surgical patients with normal baseline renal function, despite your patient having eGFR ≥60 mL/min/1.73 m². 1
• The FLASH study demonstrated significantly higher renal failure rates with HES (relative risk 1.34, p=0.05) during major abdominal surgery. 1
• Multiple studies show HES causes a decline in GFR of approximately 7 mL/min/1.73 m² per unit administered in the early postoperative period. 2, 3
• Cardiac surgery patients receiving HES as pump prime had twice the risk of postoperative AKI (adjusted OR 2.26; 95% CI 1.40-3.80). 2

Coagulopathy and Bleeding Risk

• HES is associated with hemostasis disorders and significantly higher hemorrhagic risk compared to crystalloids in major non-cardiovascular surgery. 1
• This results in higher transfusion requirements in surgical patients. 1
• The risk of surgical revision for bleeding is significantly increased (4.6% vs 1.4%, p=0.02). 2

No Mortality or Morbidity Benefit

• Meta-analyses show no improvement in mortality, major complications, or composite outcomes when comparing HES to crystalloids in surgical patients. 1
• The volume-sparing effect of HES is overestimated—the actual crystalloid-to-colloid ratio is approximately 1.8:1, not the commonly believed 3-4:1. 4

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What to Use Instead: Balanced Crystalloids

First-Line Therapy

• Administer balanced crystalloids (lactated Ringer's or Plasma-Lyte) for postoperative hypotension due to volume depletion. 1
• These solutions reduce the risk of acute kidney injury compared to 0.9% saline. 1

Dosing Strategy

• Aim for a mildly positive fluid balance of +1-2 liters by the end of resuscitation to protect kidney function while avoiding fluid overload. 1
• Administer fluid boluses guided by hemodynamic parameters (mean arterial pressure, heart rate, urine output). 1
• If using 0.9% saline, limit to maximum 1-1.5 liters to minimize hyperchloremic acidosis risk. 1

Avoid Excessive Restriction

• Stringently restrictive "zero-balance" fluid strategies increase AKI risk compared to modestly liberal regimens. 1
• A body weight increase of approximately 1.6 kg within 24 hours postoperatively is acceptable and protective. 1

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Critical Caveats

When HES Might Still Be Encountered

• While the 2026 PHOENICS trial (1,985 patients) showed non-inferiority of HES for short-term renal function in elective abdominal surgery 5, this does not override the strong guideline recommendations against routine use. 1
• The trial showed HES caused greater eGFR decline (-3.4 vs -1.0 mL/min/1.73 m²) despite meeting non-inferiority margins. 5
• Guidelines explicitly state HES should not be used until new evidence emerges, and one positive trial does not constitute sufficient evidence to change practice. 1, 6

Regulatory Context

• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation. 7
• French health authorities restrict HES to second-line treatment only when crystalloids are deemed insufficient. 1
• HES is absolutely contraindicated in critically ill patients, sepsis, severe liver disease, and pre-existing coagulopathy. 6, 7

Common Pitfall

• Do not be misled by the belief that colloids provide superior hemodynamic support—the crystalloid-to-colloid equivalence ratio is approximately 1:1 in terms of volume-sparing effects. 1
• Studies claiming HES superiority typically used inadequate control fluids (other colloids or 0.9% saline rather than balanced crystalloids) and were too small and short-duration to detect safety signals. 4

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Practical Algorithm for Postoperative Hypotension

1. Confirm volume depletion as the cause (vs. vasodilation, cardiac dysfunction, bleeding).
2. Administer balanced crystalloid boluses (250-500 mL) guided by hemodynamic response.
3. Reassess after each bolus—check blood pressure, heart rate, urine output, and clinical perfusion.
4. Continue crystalloids until euvolemia is achieved, targeting +1-2 L positive balance overall.
5. Add vasopressors (norepinephrine or phenylephrine) if hypotension persists despite adequate volume replacement.
6. Never use HES as first-line or routine therapy—the risks outweigh any theoretical benefits. 1