Hydroxyethylstärke (HES)

Abstract

Adequate volume replacement therapy is a mainstay of managing the critically ill. The ideal kind of volume replacement in this situation still remains a challenge. In spite of an immense number of contributions to this problem there is still no definite answer. The ideal volume replacement strategy should not only aim at maintaining stable systemic hemodynamics, organ perfusion and microcirculation should be guaranteed or even improved as well. Due to its excellent efficacy, hydroxyethylstarch (HES) preparations are widely used to treat hypovolemia. The different physico-chemical properties of the available HES solutions, however, should be taken into account. Anphylactoid reactions as well as negative effects on coagulation, kidney/liver function and on the immune system are frequently used arguments against the administration of HES, but they can virtually be neglected when using modern HES preparations to correct hypovolemia. There are, however, still open questions concerning the use of HES in children, pregnant patients, patients with altered kidney function and in burn patients.

Are renal adverse effects of hydroxyethyl starches merely a consequence of their incorrect use?

“…When the results of the Schortgen study appeared, which found increased ARF after HES 200/0.6 in septic patients, this was explained as a consequence of using "highly substituted HES 200/0.6" while 10% HES 200/0.5 was at the same time regarded as "a modern HES solution" with "no negative eff ect … on renal function" based on the results of the 1998 study [47]. Elsewhere, 10% HES 200/0.5 was claimed to be a "modern HES solution of medium molecular weight and medium degree of substitution" and to be "harmless in the therapy of sepsis" [15].…”

“…Elsewhere, 10% HES 200/0.5 was claimed to be a "modern HES solution of medium molecular weight and medium degree of substitution" and to be "harmless in the therapy of sepsis" [15]. "Especially in patients with total renal insuffi ciency, care should be taken to use easily degradable HES solutions with a low degree of substitution (0.4 or 0.5)" [47].…”

“…After the publication of renal side eff ects following HES 200/0.6 in patients with sepsis [6], it was argued that these eff ects were also due to the fact that an older, "less easily degradable" HES solution had been used [47]. Hence "particularly older HES solutions (HES 450/0.7, HES 200/0.6) were repeatedly associated with renal impairment" [15].…”

“…Hence "particularly older HES solutions (HES 450/0.7, HES 200/0.6) were repeatedly associated with renal impairment" [15]. If a more easily degradable HES solution with a lower degree of substitution had been used, ARF would have been prevented [14] and "Negative eff ects on coagulation, kidney/ liver function … can virtually be neglected when using modern HES preparations" [47].…”

Hydroxyethyl starch – can the safety problems be ignored?

“…Boldt [10] has recently argued that the safety problems of HES can be ignored, as long as clinicians use "modern" solutions such as HES 200/0.5 and HES 130/ 0.4. This contention needs to be critically appraised.…”