Document Detail


A systematic review of third-generation hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed.
MedLine Citation:
PMID:  21304149     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Hydroxyethyl starches (HES) are widely used for intravascular volume therapy in surgical, emergency, and intensive care patients. There are safety concerns with regard to coagulopathy, renal failure, pruritus, tissue storage, and mortality. Third-generation HES 130/0.4 is considered to have an improved risk profile. A common rationale for the use of HES is the belief that 3 to 4 times more crystalloid than colloid volume is needed to achieve similar hemodynamic end points. Our goal was to assess whether published studies on HES 130/0.4 resuscitation are sufficiently well designed to draw conclusions about the safety of this compound. In addition, we wanted to assess crystalloid-to-colloid fluid ratios in studies with goal-directed fluid regimen.
METHODS: Systematic review of randomized controlled trials in which HES 130/0.4 is used for resuscitation.
RESULTS: We identified 56 randomized controlled trials (RCTs) with HES 130/0.4 in. acute hypovolemia, mainly from the elective surgical setting (n = 45). Surgical studies were small-sized (median 25 patients in the HES groups, range 10 to 90) and of short duration (median 12 hours, range 0.5 to 144 hours). The median cumulative HES dose was 2465 mL (range 328 to 6229 mL), corresponding to 35 mL/kg in a 70-kg patient, the daily dose limit being 50 mL/kg. End points mostly addressed variable surrogate outcomes. Sixty percent of control fluids were other HES solutions, gelatins, or dextran, which have a similar risk profile. Without exception, these studies were not designed for clinically important safety outcomes, primarily because they were too small, used mostly inadequate control fluids, and had inappropriately short observation periods. Therefore, and also because of heterogeneity of patient groups and outcome definitions, results from these studies cannot be pooled. These studies do not allow any conclusion about the safety of HES 130/0.4. There is a common belief that 3 to 4 times more crystalloid than colloid volume is necessary to achieve similar hemodynamic effects. We found a considerably lower ratio in surgical studies (mean 1.8, SD 0.1).
CONCLUSIONS: In summary, the extent of fluid load reduction that can be achieved by HES 130/0.4 is overestimated. Use of older HES solutions may be associated with serious side effects, and clinicians should be aware that there is no convincing evidence that third-generation HES 130/0.4 is safe in surgical, emergency, or intensive care patients despite publication of numerous clinical studies.
Authors:
Christiane S Hartog; Matthias Kohl; Konrad Reinhart
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Publication Detail:
Type:  Comparative Study; Journal Article; Review     Date:  2011-02-08
Journal Detail:
Title:  Anesthesia and analgesia     Volume:  112     ISSN:  1526-7598     ISO Abbreviation:  Anesth. Analg.     Publication Date:  2011 Mar 
Date Detail:
Created Date:  2011-02-25     Completed Date:  2011-04-21     Revised Date:  2011-07-14    
Medline Journal Info:
Nlm Unique ID:  1310650     Medline TA:  Anesth Analg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  635-45     Citation Subset:  AIM; IM    
Affiliation:
Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller University, Erlanger Allee 101, D-07747 Jena, Germany.
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MeSH Terms
Descriptor/Qualifier:
Blood Coagulation / drug effects,  physiology
Hetastarch / adverse effects*,  therapeutic use
Humans
Hypovolemia / drug therapy,  physiopathology
Randomized Controlled Trials as Topic / adverse effects,  methods
Resuscitation / adverse effects*,  methods
Safety
Treatment Outcome
Chemical
Reg. No./Substance:
0/HES 130-0.4; 9005-27-0/Hetastarch
Comments/Corrections
Comment In:
Anesth Analg. 2011 Jun;112(6):1509; author reply 1509-10   [PMID:  21613202 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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