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Safety of HES 130/0.4 Not Yet Settled

Farag, Ehab MD, FRCA; Argalious, Maged MD, MBA; O’Hara, Jerome MD; Doyle, D. John MD, PhD

doi: 10.1213/ANE.0b013e31829691f2
Letters to the Editor: Letter to the Editor
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Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, doylej@ccf.org

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To the Editor

In a recent paper describing the safety of modern starches, Van Der Linden et al.1 did not mention the consensus statement of the European Society of Intensive Care Medicine task force on colloid use in critically ill patients recommending against the use of 6% hydroxyethyl starch (HES) 130/0.4 in this population.2 Similarly, the authors failed to cite a 2011 Cochrane review cautioning against the routine administration of HES,3 as well as a systematic review by Gattas et al.4 concluding that “there is no convincing evidence that third-generation HES 130/0.4 is safe in surgical, emergency, or intensive care patients despite publication of numerous clinical studies.”

Second, the recently published 7000-patient Crystalloid versus Hydroxyethyl Starch Trial5 showed that although there was no significant difference in 90-day mortality, patients randomized to HES 130/0.4 had more renal injury and requirement for renal-replacement therapy than those receiving saline.

Third, we suggest that the authors may have left a falsely reassuring impression of the effects of HES 130/0.4 on coagulation. The coagulation studies included in their study were small trials comparing different synthetic colloids with HES 130/0.4. However, it is now known that HES 130/0.4 administration results in a weaker, smaller clot,6 a fact that might explain the increased transfusion rate in HES 130/0.4 treated individuals with blunt trauma compared with those treated with normal saline.7

Finally, we would like to point out that synthetic colloids do not always decrease tissue edema.8 This may be because Starling’s original model of semipermeable capillaries subject to hydrostatic and oncotic pressure differences is now known to be an oversimplification.9 In fact, an intact glycocalyx and lymphatic system are crucial to avoid tissue edema.

Ehab Farag, MD, FRCA

Maged Argalious, MD, MBA

Jerome O’Hara, MD

D. John Doyle, MD, PhD

Department of General Anesthesiology

Cleveland Clinic

Cleveland, Ohio

doylej@ccf.org

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REFERENCES

1. Van Der Linden P, James M, Mythen M, Weiskopf RB. Safety of modern starches used during surgery. Anesth Analg. 2013;116:35–48
2. Reinhart K, Perner A, Sprung CL, Jaeschke R, Schortgen F, Johan Groeneveld AB, Beale R, Hartog CSEuropean Society of Intensive Care Medicine. . Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients. Intensive Care Med. 2012;38:368–83
3. Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev. 2010;1:CD007594
4. Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer SCHEST Management Committee. . Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesth Analg. 2012;114:159–69
5. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, Glass P, Lipman J, Liu B, McArthur C, McGuinness S, Rajbhandari D, Taylor CB, Webb SACHEST Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. . Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367:1901–11
6. James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth. 2011;107:693–702
7. Hartog CS, Reuter D, Loesche W, Hofmann M, Reinhart K. Influence of hydroxyethyl starch (HES) 130/0.4 on hemostasis as measured by viscoelastic device analysis: a systematic review. Intensive Care Med. 2011;37:1725–37
8. Jacob M, Bruegger D, Rehm M, Welsch U, Conzen P, Becker BF. Contrasting effects of colloid and crystalloid resuscitation fluids on cardiac vascular permeability. Anesthesiology. 2006;104:1223–31
9. Woodcock TE, Woodcock TM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth. 2012;108:384–94
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