No abstract

Proper fluid management is crucial for the management of critically ill patients. However, there is a continuing debate about the choice of the fluid, i.e., crystalloid vs. colloid. Colloid solution is theoretically advantageous to the crystalloid because of larger volume effect and less interstitial fluid accumulation, and hydroxyethyl starch (HES) is most frequently used for perioperative setting. Nevertheless, application of HES solution is relatively limited due to its side effects including renal toxicity and coagulopathy. Since prolonged presence of large HES molecule is responsible for these side effects, rapidly degradable HES solution with low degree of substitution (tetrastarch) supposedly has less potential for negative effects. Thus, tetrastarch may be more frequently used in the ICU setting. However, several large-scale randomized trials reported that administration of tetrastarch solution to the patients with severe sepsis has negative effects on mortality and renal function. These results triggered further debate and regulatory responses around the world. This narrative review intended to describe the currently available evidence about the advantages and disadvantages of tetrastarch in the ICU setting.

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Plasma substitutes are mainly used to maintain circulating blood volume during massive hemorrhage. These solutions are used to bridge the gap between fluid therapy with crystalloid and that with albumin since plasma substitutes are usually less expensive than albumin while large doses of such synthetic colloids may negatively affect the coagulation system and renal integrity. Since an effective coagulation system depends on the presence of large HES molecule in the circulation, middlemolecular-weight, rapidly degradable hydroxyethyl starch (HES) is generally used for the treatment of massive hemorrhage. Recent randomized controlled trials revealed that middle-molecular-weight, rapidly degradable HES significantly increased the risk of renal injury in critically ill patients. Such studies are characterized by the repetitive administration of HES at the high end of the daily allowable limit. In contrast, better renal effects were reported when middle-molecular-weight, rapidly degradable HES was used for trauma resuscitation. Based on these data, we assume that HES use against massive hemorrhage is safe when used for resuscitative purposes within the allowable limit.

153-85152-17-6 Liberal fluid strategy mostly using crystalloid solution to achieve adequate blood pressure and urine output has been widely used in intraoperative fluid management. However, recent increases in high-risk surgical patients and trends toward early recovery after surgery require more advanced strategies of fluid management. In high-risk surgical patients, the advantages of fluid optimization using less-invasive hemodynamic monitor and synthetic colloid administration, have been reported. For patients in early recovery after surgery, a restrictive fluid strategy has successfully reduced gastrointestinal complications and contributed to achieving the goal of early recovery. For these reasons, goal-directed fluid management, which includes both fluid optimization and fluid restriction, is a logical choice as a future trend in intraoperative fluid management.