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In February 2013, two good quality systematic reviews were published that questioned the use of hydroxyethyl starch administration in critically ill patients. Hydroxyethyl starches are routinely used for volume resuscitation in clinical practice despite a lack of convincing evidence of benefit, and a safety profile that has been increasingly questioned.

The first review published in JAMA (Zarychanski, 2013), compared hydroxyethyl starch with other intravenous fluid resuscitation therapies (crystalloids, albumin, or gelatin) in critically ill patients. After excluding seven trials from an author whose other research has been retracted because of scientific misconduct (Editors in Chief, 2011), there was clear evidence that hydroxyethyl starch significantly increased the risk of death and acute kidney injury. The authors concluded that hydroxyethyl starch for acute volume resuscitation should not be used due to these serious safety concerns. This conclusion is reliable. An accompanying editorial (Antonelli, 2013) explains why this conclusion differs from that of a recent Cochrane review, which included only crystalloids as a comparator and had fewer retracted studies (Perel, 2012). It highlights the need to update clinical guidelines in light of this new evidence.

A second systematic review published in the BMJ (Haase, 2013) examined the effects of hydroxyethyl starch compared to other fluid therapies (crystalloid or albumin) on risk of death, kidney injury, bleeding, and serious adverse events in patients with sepsis. The review found that the use of hydroxyethyl starch increased the use of renal replacement therapy and red blood cell transfusions and resulted in more serious adverse events compared to other fluid therapies. The authors concluded that hydroxyethyl starch is unlikely to provide overall clinical benefit for patients with sepsis. This conclusion is reliable.

These reviews update an existing evidence base which has consistently questioned the use and effects of hydroxyethyl starch on critically ill patients (Schierhout, 1998; Wilkes, 2001; Pichon Riviere, 2006; Wiedermann, 2008; Dart, 2010; Mitchell, 2011; Hartog, 2011; Gattas, 2012; Bunn, 2012). All of these reviews and other critically appraised systematic reviews and economic evaluations relevant to the management of critically ill patients are available on the CRD Databases.

References

Antonelli M, Sandroni C. Hydroxyethyl Starch for Intravenous Volume Replacement: More Harm Than Benefit. JAMA 2013; 309: 723-724.

Editors-in-Chief. Joint Statement Regarding Published Clinical Trials Conducted without IRB Approval by Joachim Boldt. 12 March 2011.

Haase N, Perner A, Inkeri Hennings L, Siegemund M, Lauridsen B, Wetterslev M, Wetterslev J. Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis. BMJ 2013; 346: f839.

Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2012; Issue 6. Art. No.: CD000567. DOI: 10.1002/14651858.CD000567.pub5

Zarychanski R, Abou-Setta AM, Turgeon AF, Houston BL, McIntyre L, Marshall JC, Fergusson DA. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA 2013; 309: 678-688.

Other reviews

Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 1998; 316: 961-964.

Wilkes MM, Navickis RJ, Sibbald WJ. Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding. Annals of Thoracic Surgery 2001; 72: 527-533.

Pichon Riviere A, Augustovski F, Alcaraz A, Bardach A, Ferrante D, Garcia Marti S, Glujovsky D, Lopez A, Regueiro A. Usefulness of hydroxyethyl starch (HES) as plasma expander. Buenos Aires: Institute for Clinical Effectiveness and Health Policy (IECS). Informe de Respuesta Rapida No.65. 2006.

Wiedermann CJ. Systematic review of randomized clinical trials on the use of hydroxyethyl starch for fluid management in sepsis. BMC Emergency Medicine 2008; 8:1.

Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database of Systematic Reviews 2010; Issue 1. Art. No.: CD007594. DOI: 10.1002/14651858.CD007594.pub2.

Mitchell MD, Williams K, Fishman N. Impact of retracted articles on the evidence base for hydroxyethyl starch. Philadelphia: Center for Evidence-based Practice (CEP), 2011.

Hartog CS, Kohl M, Reinhart K. A systematic review of third-generation hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed. Anesthesia and Analgesia 2011; 112: 635-45.

Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer S, The Crystalloid versus Hydroxyethyl Starch Trial (CHEST) Management Committee. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesthesia and Analgesia 2012; 114: 159-169.

Bunn F, Trivedi D. Colloid solutions for fluid resuscitation. Cochrane Database of Systematic Reviews 2012; Issue 7. Art. No.: CD001319. DOI: 10.1002/14651858.CD001319.pub5.