Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review

Abstract

Background: Perioperative fluid managementincluding the type, dose, and timing of administration-directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate. Main text: The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flowrelated variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications.

Effects of Different Types of Early Restrictive Fluid Resuscitation on Immune Function and Multiorgan Damage on Hemorrhagic Shock Rat Model in a Hypothermic Environment

“…We observed that the early nonrestricted entry of large amounts of fluid into the bloodstream caused dilution of coagulation factors and reduced platelet function, resulting in further deterioration of coagulation and that the application of LR rehydration fluids during restrictive resuscitation had a lower effect on coagulation than HES. The hydroxyethyl starch could inactivate or degrade the coagulation factor V, factor VIII, and von Willebrand factor through combination [ 17 ]. In addition, hydroxyethyl starch reduces the expression of platelet glycoproteins Ib and IIb/IIIa and inhibits the binding of fibrinogen and activated platelets, thereby inhibiting endogenous coagulation and platelet adhesion and aggregation [ 17 ].…”

“…The hydroxyethyl starch could inactivate or degrade the coagulation factor V, factor VIII, and von Willebrand factor through combination [ 17 ]. In addition, hydroxyethyl starch reduces the expression of platelet glycoproteins Ib and IIb/IIIa and inhibits the binding of fibrinogen and activated platelets, thereby inhibiting endogenous coagulation and platelet adhesion and aggregation [ 17 ]. Other studies have demonstrated that hydroxyethyl starch can inhibit platelet function and increase bleeding tendency by blocking ligand binding to surface receptors and nonspecific modification of cell membrane structure [ 18 ].…”

Hydroxyl Ethyl Starch (HES) Preserves Intrarenal Microcirculatory Perfusion Shown by Contrast-Enhanced Ultrasound (Ceus), and Renal Function in a Severe Hemodilution Model in Pigs

“…Dilutional anemia associated with ANH, however, has been identified as an important risk factor in the development of acute kidney injury (AKI) among patients undergoing cardiopulmonary bypass (1,2). Although albumin can be used for this purpose its scarcity and costs make synthetic colloids such as hydroxyl ethyl starch (HES) and attractive alternative in the perioperative setting (3).…”

Restricted, optimized or liberal fluid strategy in thoracic surgery

“…In contrast with the first generations of high molecular weight HES that were shown to increase bleeding by interference with platelets and coagulation factors (e.g., von Willebrandt factor and fibrinogen), the third generation of HES has a lower-molecular weight (130 kd), a molar substitution ratio of 0.5 and is suspended in a balanced salt solution at a lower concentration (6%) that altogether confer a safer risk profile while keeping the volemic expansion advantage with prolonged IVS persistence and lesser positive fluid balance. [ 51 ]…”