Share this article on:

Comparison of hydroxyethyl starch colloids with crystalloids for surgical patients: A systematic review and meta-analysis

Raiman, Mohamed; Mitchell, Colin G.; Biccard, Bruce M.; Rodseth, Reitze N.

European Journal of Anaesthesiology (EJA): January 2016 - Volume 33 - Issue 1 - p 42–48
doi: 10.1097/EJA.0000000000000328
Perioperative medicine

BACKGROUND Fluid therapy is one of the most ubiquitous medical therapeutic interventions. There is a debate over whether colloids or crystalloids are better for fluid resuscitation. Recent large trials and meta-analyses suggest no mortality benefit and possible harm with hydroxyethyl starch (HES) use. However, these trials were conducted in critically ill and septic patients and their applicability to perioperative patients has been challenged.

OBJECTIVE We aimed to evaluate the impact of HES use in scheduled and elective surgical patients.

DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs).

ELIGIBILITY CRITERIA Only RCTs comparing the use of the synthetic colloid HES with any crystalloid in adults undergoing noncardiac surgery (up to 24 h postop) were considered eligible. For each eligible trial, we extracted the outcomes of all-cause mortality within 90 days, length of hospital stay, major infectious complications, acute kidney injury (AKI) and renal replacement therapy (RRT).

RESULTS We identified 1555 citations, selected 90 for full-text evaluation, and identified 13 eligible RCTs. Trials were small (n = 20 to 202) with low event rates. There was a trend to increased mortality with HES within 90 days [13/373 vs. 3/368; risk ratio 2.97; 95% confidence interval (95% CI) 0.96 to 9.19; I 2 = 0%], no difference in AKI and RRT (risk ratio 1.11; 95% CI 0.26 to 4.69; I 2 = 34%), and no difference in major infectious complications (risk ratio 1.19; 95% CI 0.59 to 2.39; I 2 = 0%). Patients resuscitated with HES had a shorter length of hospital stay (mean difference −1.52 days; 95% CI −2.87 to −0.18), although heterogeneity was high (I 2 = 90%).

CONCLUSION This meta-analysis, based on small studies with low event rates, suggests that there are currently insufficient data to identify a difference in outcomes associated with crystalloids and HES in scheduled or elective noncardiac surgery.

Supplemental Digital Content is available in the text

From the Department of Anaesthesia, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (MR), Department of Anaesthesia, Grey's Hospital, Pietermaritzburg (CGM), Perioperative Research Group, Department of Anaesthesia, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban (BMB), Perioperative Research Group, Department of Anaesthesia, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa, and Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA (RNR)

Correspondence to Mohamed Raiman, Department of Anaesthesia, Inkosi Albert Luthuli Central Hospital, Private Bag X03, Mayville, Durban 4058, South Africa E-mail:

Published online 8 September 2015

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (

© 2016 European Society of Anaesthesiology