The dilemma for using hydroxyethyl starch solutions for perioperative fluid management

Abstract

Hydroxyethyl starch is a colloid plasma expander that has recently been reviewed by the European Medicines Agency (EMA) following safety concerns in critically ill patients or in patients with sepsis. The EMA decided to restrict HES use in these patients but continues to allow its use in surgical and trauma patients who suffer from hypovolemia due to blood loss that cannot be corrected by crystalloids alone. This narrative review explains the basis for initial approval of HES, the presumed action of HES as plasma expander, and the mechanisms of its adverse effects on coagulation and on extravascular tissue uptake, especially in the kidneys with resulting renal failure, and presents an overview of recent important studies with a focus on surgery and trauma. No definitive, large-scale randomized controlled trials with patient-relevant outcomes and long-term follow-up exist in this population. Existing studies provide no assurance of a lower risk of coagulopathy, mortality, or kidney failure than in other critically ill patients. There are sufficient data to suggest that HES has similar risks also in these patients and should therefore be avoided.