Early fluid resuscitation with hyperoncotic hydroxyethyl starch 200/0.5 (10%) in severe burn injury

Abstract

IntroductionDespite large experience in the management of severe burn injury, there are still controversies regarding the best type of fluid resuscitation, especially during the first 24 hours after the trauma. Therefore, our study addressed the question whether hyperoncotic hydroxyethyl starch (HES) 200/0.5 (10%) administered in combination with crystalloids within the first 24 hours after injury is as effective as 'crystalloids only' in severe burn injury patients.Methods30 consecutive patients were enrolled to this prospective interventional open label study and assigned either to a traditional 'crystalloids only' or to a 'HES 200/0.5 (10%)' volume resuscitation protocol. Total amount of fluid administration, complications such as pulmonary failure, abdominal compartment syndrome, sepsis, renal failure and overall mortality were assessed. Cox proportional hazard regression analysis was performed for binary outcomes and adjustment for potential confounders was done in the multivariate regression models. For continuous outcome parameters multiple linear regression analysis was used.ResultsGroup differences between patients receiving crystalloids only or HES 200/0.5 (10%) were not statistically significant. However, a large effect towards increased overall mortality (adjusted hazard ratio 7.12; P = 0.16) in the HES 200/0.5 (10%) group as compared to the crystalloids only group (43.8% versus 14.3%) was present. Similarly, the incidence of renal failure was 25.0% in the HES 200/0.5 (10%) group versus 7.1% in the crystalloid only group (adjusted hazard ratio 6.16; P = 0.42).ConclusionsThis small study indicates that the application of hyperoncotic HES 200/0.5 (10%) within the first 24 hours after severe burn injury may be associated with fatal outcome and should therefore be used with caution.Trial registrationNCT01120730.

Burns

“…Some have argued that administration of hypertonic hydroxyethyl starch 200/0.5 (10%) administered in combination with crystalloids within the first 24 hours after injury can improve survival rates. 85 However, Béchir et al 85 showed that rather than a benefit in treatment, there was an increased mortality and should therefore be used with caution moving forward. This is also seen with NO, which has been used in burn patients to treat hypoxic pulmonary vasoconstriction and to improve ventilation/perfusion mismatches and therefore tissue oxygenation.…”

“…90 Although MSCs with self-renewable and multipotential properties provide a vital modality of repair and regeneration, their vitality varies according to the donor age and health condition. 75,85,86 Research in recent years has suggested that umbilical cord-derived MSCs exhibit higher occurrence of colony-forming unit fibroblast than bone marrow-derived MSCs, suggesting more primitive features. 75 …”

Strategies for Intravenous Fluid Resuscitation in Trauma Patients

“…Hyperoncotic colloids worsen outcome, but the role of albumin or synthetic colloids (e.g., HES) is less clear [102–104]. Colloid solutions shorten the time to achieve hemodynamic goals, but increase expense without a concomitant improvement in outcome.…”

The Bellamy challenge: it's about time

“…The authors concluded that in those patients who received 6% HES there was significantly higher renal dysfunction and death. Béchir and colleagues also cautioned against the use of a second generation 10% HES (HES 200/0.5) in humans, as they found it was associated with fatal outcomes within the first 24 h after severe burn injury 30. Hartog and colleagues further questioned the use of a third generation HES (Voluven; HES 130/0.4) after analysis of 56 randomised trials, and they concluded that safety has not been adequately addressed 28.…”