Hydroxyethyl Starch (Hetastarch)

Indications

  • Intravenous Fluid Resuscitation
  • Sepsis (see Sepsis, Sepsis)

Pharmacology

  • xxxx

Metabolism

  • xxx

Administration

  • IV

Dose Adjustment

  • Hepatic
  • Renal

Adverse Effects

Renal Adverse Effects

Increased Risk of Acute Kidney Injury (AKI) (see Acute Kidney Injury, Acute Kidney Injury)

  • Clinical Efficacy
    • ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient (Am J Respir Crit care Med, 2010) [MEDLINE]
      • Hyper-Oncotic Fluids (Hydroxyethyl Starch, Dextrans, 20-25% Albumin) are Not Recommended, Due to Their Risk of Renal Dysfunction
      • Hypo-Oncotic Colloids (5% Albumin) are as Effective as Crystalloids
    • Australian/New Zealand Crystalloid vs Hydroxyethyl Starch Trial (CHEST): Comparing Hydroxyethyl Starch vs Normal Saline Resuscitation in ICU Patients (NEJM, 2012) [MEDLINE]
      • No Difference in 90-Day Mortality Between 6% Hydroxyethyl Starch vs Normal Saline
      • However, Hydroxyethyl Starch Group Had Higher Need for Hemodialysis
    • Fluids in Sepsis and Septic Shock Group Study (Ann Intern Med, 2014) [MEDLINE]: network meta-analysis (14 studies, n = 18,916 patients)
      • Network Meta-Analysis at the 4-Node Level: higher mortality with starches than with crystalloids (high confidence)
      • Network Meta-Analysis at the 4-Node Level: lower mortality with albumin than with crystalloids (moderate confidence) or starches (moderate confidence)
      • Network Meta-Analysis at the 6-Node Level: lower mortality with albumin than with saline (moderate confidence) and low-molecular-weight starch (low confidence) and with balanced crystalloids than with saline (low confidence) and low and high-molecular-weight starches (moderate confidence)
      • Conclusions: resuscitation with balanced crystalloids (lactated ringers, etc) or albumin was associated with decreased mortality, as compared to other fluids

Other Adverse Effects

  • xxx

References

  • SAFE Trial: A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247–2256 [MEDLINE]
  • An Official ATS/ERS/ESICM/SCCM/SRLF Statement:  Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine.  Am J Respir Crit Care Med  2010;  181:1128-1155.  DOI:  10.1164/rccm.200711-1664ST [MEDLINE]
  • The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Crit Care Med. 2011 Feb;39(2):386-91. doi: 10.1097/CCM.0b013e3181ffe217 [MEDLINE]
  • Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012 Oct 17;308(15):1566-72. doi: 10.1001/jama.2012.13356 [MEDLINE]
  • CHEST Trial. Hydroxyethyl starch or saline for fluid resuscitation in intensive care.  N Engl J Med  Nov 15, 2012;  367(20):1901-1911.  DOI: 10.1056/NEJMoa1209759.  Epub Oct 17, 2012 [MEDLINE]
  • Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013 Nov 6;310(17):1809-17. doi: 10.1001/jama.2013.280502 [MEDLINE]
  • Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2014 Jul 22. doi: 10.7326/M14-0178 [MEDLINE]
  • ALBIOS Study. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014 Apr 10;370(15):1412-21. doi: 10.1056/NEJMoa1305727. Epub 2014 Mar 18 [MEDLINE]