Hydroxyethyl Starch (HES) Safety Concerns and Clinical Applications

Definition and Clinical Applications

Hydroxyethyl starch (HES) has been used as a colloidal volume-expanding solution for fluid resuscitation in hypovolemic states, according to the American Society of Anesthesiologists 1, 2
In endoscopic procedures, HES can be used as a relatively inexpensive submucosal lifting agent that produces longer-lasting lift compared to normal saline for endoscopic mucosal resection, as recommended by the American Society for Gastrointestinal Endoscopy 2

HES is contraindicated in critically ill adult patients, including those with sepsis, due to increased risk of mortality and renal replacement therapy, as stated by the European Medicines Agency and the American College of Critical Care Medicine 1, 3
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 1
Additional contraindications include severe liver disease, as noted by the Society of Critical Care Medicine 4
Clinical conditions where volume overload is a potential problem, such as congestive heart failure and renal disease, are also contraindications for HES use, according to the American Heart Association and the National Kidney Foundation 5
Pre-existing coagulation or bleeding disorders are contraindications for HES use, as stated by the American College of Chest Physicians 6

The CHEST study reported increased incidence of renal replacement therapy in the HES group compared to isotonic crystalloids, with a relative risk of 1.17, as published by the American Thoracic Society 1

Crystalloids are recommended as the initial fluid of choice in resuscitation of patients with severe sepsis and septic shock, with a Grade 1B recommendation from the Society of Critical Care Medicine 4
Balanced crystalloids should be used in preference to 0.9% normal saline for resuscitation and to maintain intravascular volume, as recommended by the World Federation of Societies of Anaesthesiologists 7
For emergency laparotomy, the use of HES solutions is not recommended due to the increased risk of kidney failure and mortality, as stated by the World Society of Emergency Surgery 7
In trauma patients, if colloids are administered, they should be used within the prescribed limits for each solution, with a Grade 1B recommendation from the European Society of Intensive Care Medicine 6

Balanced crystalloid solutions are preferred for most resuscitation scenarios, as recommended by the American College of Surgeons and the World Federation of Societies of Anaesthesiologists 7, 8
For patients requiring substantial amounts of crystalloids, albumin may be considered in the fluid resuscitation of severe sepsis and septic shock, with a Grade 2C recommendation from the Society of Critical Care Medicine 4
Isotonic crystalloids are the preferred initial fluid for resuscitation in most clinical scenarios, as stated by the American Heart Association and the National Kidney Foundation 5

The use of hydroxyethyl starch (HES) in septic patients increases the risk of acute kidney injury (RR 1.60) without survival benefit 9
The 6S trial found increased mortality and need for renal replacement therapy with HES versus crystalloids 9

The American Heart Association recommends administering at least 30 mL/kg of crystalloid (lactated Ringer's or Plasma-Lyte) within the first 3 hours for hypovolemia in pediatric patients, with 20 mL/kg boluses of isotonic crystalloid, repeating as needed if perfusion fails to improve 10, 11
Albumin may be considered for severe sepsis/septic shock after substantial crystalloid administration, particularly in patients with cirrhosis and sepsis-induced hypotension, with a dosing regimen of 20% albumin at 20g every 8 hours for 3 days 9, 12

Dynamic monitoring, including assessment of stroke volume variation, pulse pressure variation, or passive leg raise response, should be used to guide fluid administration 12
The goal of fluid resuscitation is to achieve adequate tissue perfusion without fluid overload, with monitoring of mean arterial pressure, heart rate, urine output, and central venous pressure 9, 12