1
|
van Galen G, Hallowell G. Hydroxyethyl starches in equine medicine. J Vet Emerg Crit Care (San Antonio) 2019; 29:349-359. [PMID: 31228334 DOI: 10.1111/vec.12854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/11/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review and discuss the use of hydroxyethyl starches (HES) in equine veterinary medicine, and to provide recommendations for its use. DATA SOURCES Veterinary and human peer-reviewed medical literature including scientific reviews, meta-analyses, and original research articles. HUMAN DATA SYNTHESIS Increasing evidences on adverse effects after HES use and decreasing support for beneficial effects with regards to volume expansion and colloid osmotic pressure (COP) support in critically ill subjects have led to a recent guideline to limit the use of HES in critically ill people. EQUINE VETERINARY DATA SYNTHESIS The rationale for HES use in horses is mainly extrapolated from human medicine, and very limited studies in horses are available. There is limited evidence suggesting a superiority of volume expansion effects of HES over crystalloids. The potential for HES to increase and maintain COP is well supported, but there is no evidence that maintaining or increasing plasma COP influences outcome, tissue edema formation, or rates of complications that potentially relate to edema formation. HES induce dose-dependent changes in coagulopathic parameters, but there is no evidence that HES causes clinical coagulopathies. Insufficient data are available on other adverse effects such as acute kidney injury, or mortality in horses. The use of HES should be restricted in septic patients, but may still have some use in cases of hemorrhagic shock resuscitation, hypoalbuminemia, or perioperative fluid replacement. CONCLUSION The evidence supporting the use of HES in horses is weak due to lack of species-specific investigations. Acknowledging species differences, the use of HES should be judicious, yet with some recognition of its benefits in particular cases. More research is necessary to improve knowledge on use of HES in horses and to establish better future recommendations.
Collapse
Affiliation(s)
- Gaby van Galen
- Medicine and Surgery, Department of Large Animal Science, University of Copenhagen, Copenhagen, Denmark
| | - Gayle Hallowell
- School of Veterinary Medicine and Surgery, University of Nottingham, Nottingham, UK
| |
Collapse
|
2
|
Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. DATA SOURCES Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HUMAN DATA SYNTHESIS HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. VETERINARY DATA SYNTHESIS The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. CONCLUSIONS Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.
Collapse
Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | | | | |
Collapse
|
3
|
Wong YL, Lautenschläger I, Zitta K, Schildhauer C, Parczany K, Röcken C, Steinfath M, Weiler N, Albrecht M. Adverse effects of hydroxyethyl starch (HES 130/0.4) on intestinal barrier integrity and metabolic function are abrogated by supplementation with Albumin. J Transl Med 2016; 14:60. [PMID: 26920368 PMCID: PMC4769564 DOI: 10.1186/s12967-016-0810-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/07/2016] [Indexed: 12/29/2022] Open
Abstract
Background Volume resuscitation with hydroxyethyl starch (HES) is controversially discussed and we recently showed that HES perfusion impairs endothelial and epithelial intestinal barrier integrity. Here we investigated whether Albumin containing HES solutions are superior to HES alone in maintaining intestinal barrier function. Methods An isolated perfused model of the mouse small intestine was used to investigate the effects of: (i) 3 % Albumin (Alb), (ii) 3 % HES or (iii) 1.5 % HES/1.5 % Albumin (HES/Alb). Intestinal morphology, cell damage, metabolic functions, fluid shifts and endothelial/epithelial barrier permeability were evaluated. Potentially involved signaling mechanisms (Erk1/2, Akt and Stat5 phosphorylation) were screened. Results HES induced histomorphological damage (p < 0.01 vs. Alb), by trend elevated the amount of luminal intestinal fatty acid binding protein and reduced galactose uptake (p < 0.001 vs. Alb). Luminal and lymphatic flow rates were increased (p < 0.001 vs. Alb), while vascular flow was decreased (p < 0.001 vs. Alb) during HES perfusion. HES also increased the vascular to luminal FITC-dextran transfer (p < 0.001 vs. Alb), pointing towards a fluid shift from the vascular to the luminal and lymphatic compartments during HES perfusion. Addition of Alb (HES/Alb) reversed all adverse effects of HES (p < 0.05 vs. HES), restored barrier integrity (p < 0.05 vs. HES) and improved metabolic function of the intestine (p < 0.001 vs. HES; p < 0.05 vs. Alb). Mechanistically, HES/Alb perfusion resulted in an increased phosphorylation of Erk1/2 and Akt kinases (p < 0.001 vs. HES), while Stat5 remained unchanged. Conclusions Albumin supplementation abrogates the adverse effects of HES in the intestine and underlying mechanism may function via phosphorylation of Erk1/2 and Akt. Albumin containing HES solutions are superior to HES alone and may improve the suitability of HES in the clinic. Electronic supplementary material The online version of this article (doi:10.1186/s12967-016-0810-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yuk Lung Wong
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Ingmar Lautenschläger
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Christin Schildhauer
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Kerstin Parczany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany.
| | - Markus Steinfath
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Schwanenweg 21, 24105, Kiel, Germany.
| |
Collapse
|
4
|
Wong YL, Lautenschläger I, Dombrowsky H, Zitta K, Bein B, Krause T, Goldmann T, Frerichs I, Steinfath M, Weiler N, Albrecht M. Hydroxyethyl starch (HES 130/0.4) impairs intestinal barrier integrity and metabolic function: findings from a mouse model of the isolated perfused small intestine. PLoS One 2015; 10:e0121497. [PMID: 25799493 PMCID: PMC4370845 DOI: 10.1371/journal.pone.0121497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 02/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The application of hydroxyethyl starch (HES) for volume resuscitation is controversially discussed and clinical studies have suggested adverse effects of HES substitution, leading to increased patient mortality. Although, the intestine is of high clinical relevance and plays a crucial role in sepsis and inflammation, information about the effects of HES on intestinal function and barrier integrity is very scarce. We therefore evaluated the effects of clinically relevant concentrations of HES on intestinal function and barrier integrity employing an isolated perfused model of the mouse small intestine. METHODS An isolated perfused model of the mouse small intestine was established and intestines were vascularly perfused with a modified Krebs-Henseleit buffer containing 3% Albumin (N=7) or 3% HES (130/0.4; N=7). Intestinal metabolic function (galactose uptake, lactate-to-pyruvate ratio), edema formation (wet-to-dry weight ratio), morphology (histological and electron microscopical analysis), fluid shifts within the vascular, lymphatic and luminal compartments, as well as endothelial and epithelial barrier permeability (FITC-dextran translocation) were evaluated in both groups. RESULTS Compared to the Albumin group, HES perfusion did not significantly change the wet-to-dry weight ratio and lactate-to-pyruvate ratio. However, perfusing the small intestine with 3% HES resulted in a significant loss of vascular fluid (p<0.01), an increased fluid accumulation in the intestinal lumen (p<0.001), an enhanced translocation of FITC-dextran from the vascular to the luminal compartment (p<0.001) and a significantly impaired intestinal galactose uptake (p<0.001). Morphologically, these findings were associated with an aggregation of intracellular vacuoles within the intestinal epithelial cells and enlarged intercellular spaces. CONCLUSION A vascular perfusion with 3% HES impairs the endothelial and epithelial barrier integrity as well as metabolic function of the small intestine.
Collapse
Affiliation(s)
- Yuk Lung Wong
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
- Division of Barrier Integrity, Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany
| | - Ingmar Lautenschläger
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
- Division of Barrier Integrity, Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany
| | - Heike Dombrowsky
- Division of Barrier Integrity, Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany
| | - Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Berthold Bein
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Thorsten Krause
- Division of Mucosal Immunology and Diagnostics, Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany
| | - Torsten Goldmann
- Division of Clinical and Experimental Pathology, Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany
| | - Inez Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Markus Steinfath
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| |
Collapse
|
5
|
Vuiblet V, Nguyen TT, Wynckel A, Fere M, Van-Gulick L, Untereiner V, Birembaut P, Rieu P, Piot O. Contribution of Raman spectroscopy in nephrology: a candidate technique to detect hydroxyethyl starch of third generation in osmotic renal lesions. Analyst 2015; 140:7382-90. [DOI: 10.1039/c5an00821b] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Raman spectroscopy, a candidate tool for detection of HES, a volume expander administrated after hemodynamic instability, in the kidney.
Collapse
Affiliation(s)
- V. Vuiblet
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
- Nephrology Division
| | - T. T. Nguyen
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
| | - A. Wynckel
- Nephrology Division
- Maison Blanche University Hospital
- Reims
- France
| | - M. Fere
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
| | - L. Van-Gulick
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
| | - V. Untereiner
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
| | - P. Birembaut
- Histology Laboratory Pol Bouin
- Maison Blanche University Hospital
- Reims
- France
| | - P. Rieu
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
- Nephrology Division
| | - O. Piot
- UMR CNRS 7369 MEDyC
- Université de Reims Champagne-Ardenne
- Reims
- France
- PICT (Cellular and Tissular Imaging Platform)
| |
Collapse
|
6
|
Abstract
BACKGROUND Within the framework of a risk assessment procedure the Committee for Risk Assessment of Pharmacovigilance (PRAC) of the European Medicines Agency (EMA) came to the conclusion that the benefits of hydroxylethyl starch infusion solutions (HES) no longer outweighed the risks and on 14 June 2013 recommended that approval should be suspended. Until the procedure has finally been concluded, which could last several months, the Federal Institute for Drugs and Medical Products (BfArM) has recommended that HES should not be used. AIM The aim of this article is to present the data situation in the most objective and compact way and to ultimately give the reader the foundations in order to be able to form a personal opinion. In addition an attempt will be made to describe a concept how infusion therapy can be carried out without using hydroxyethyl starch (HES). MATERIAL AND METHODS The background to this decision is given based on a review of the literature and the relevance for intensive care, emergency and perioperative medicine is assessed. Furthermore, a concept of infusion therapy without hydroxyethyl starch is formulated also based on the results of current studies. RESULTS For infusion regimens without HES it should be noted that gelatin represents a considerable risk for anaphylactic reactions, that transfer of the new variants of Creutzfeldt-Jacob disease (bovine spongiform encephalopathy BSE) cannot fundamentally be excluded and that some evidence has been found that gelatin can cause kidney injury, probably in a similar way to HES. With respect to the cost-benefit analysis of infusion solutions, blood loss in adults of approximately 1-1.5 l can be substituted by balanced crystalloids (basic therapy 4-5 times compared to the amount of blood lost). For larger blood losses small amounts of hyperoncotic albumin solution (20 %) or alternatively 5 % albumin solution can be used. The 20 % albumin solution seems to have some advantages because it has a higher volume effect (approximately 200 %) and can be more favourable for the fluid balance than 5 % albumin solution. Blood losses greater than 2-3 l normally also require administration of blood products (e.g. fresh frozen plasma FFP and erythrocyte concentrates EC). CONCLUSIONS The third generation HES solutions cannot be completely replaced by other colloids and in future crystalloids will more strongly again broadly form the basis for infusion therapy. In this aspect balanced crystalloids have priority with respect to the acid-base equilibrium. The history of HES has impressively shown that infusion therapy must be adjusted on a scientifically founded basis, whether in intensive care medicine, perioperative or emergency medicine. Large prospective studies with clinically relevant endpoints are urgently needed.
Collapse
|
7
|
Wiedermann CJ, Joannidis M. Accumulation of hydroxyethyl starch in human and animal tissues: a systematic review. Intensive Care Med 2014; 40:160-170. [PMID: 24257970 PMCID: PMC7728635 DOI: 10.1007/s00134-013-3156-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 11/05/2013] [Indexed: 12/16/2022]
Abstract
PURPOSE To systematically review clinical and preclinical data on hydroxyethyl starch (HES) tissue storage. METHODS MEDLINE (PubMed) was searched and abstracts were screened using defined criteria to identify articles containing original data on HES tissue accumulation. RESULTS Forty-eight studies were included: 37 human studies with a total of 635 patients and 11 animal studies. The most frequent indication for fluid infusion was surgery accounting for 282 patients (45.9%). HES localization in skin was shown by 17 studies, in kidney by 12, in liver by 8, and in bone marrow by 5. Additional sites of HES deposition were lymph nodes, spleen, lung, pancreas, intestine, muscle, trophoblast, and placental stroma. Among major organs the highest measured tissue concentration of HES was in the kidney. HES uptake into intracellular vacuoles was observed by 30 min after infusion. Storage was cumulative, increasing in proportion to dose, although in 15% of patients storage and associated symptoms were demonstrated at the lowest cumulative doses (0.4 g kg(-1)). Some HES deposits were extremely long-lasting, persisting for 8 years or more in skin and 10 years in kidney. Pruritus associated with HES storage was described in 17 studies and renal dysfunction in ten studies. In one included randomized trial, HES infusion produced osmotic nephrosis-like lesions indicative of HES storage (p = 0.01) and also increased the need for renal replacement therapy (odds ratio, 9.50; 95% confidence interval, 1.09-82.7; p = 0.02). The tissue distribution of HES was generally similar in animals and humans. CONCLUSIONS Tissue storage of HES is widespread, rapid, cumulative, frequently long-lasting, and potentially harmful.
Collapse
Affiliation(s)
- Christian J Wiedermann
- Department of Internal Medicine, Central Hospital of Bolzano, Lorenz-Böhler-Street 5, 39100, Bolzano, Italy.
| | - Michael Joannidis
- Division of Emergency and Intensive Care Medicine, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
8
|
Affiliation(s)
- Astrid Stumpf
- Department of Psychosomatics and Psychotherapy; Competence Center of Chronic Pruritus; University Hospital Münster; Münster; Germany
| | - Sonja Ständer
- Department of Dermatology; Competence Center of Chronic Pruritus; University Hospital Münster; Münster; Germany
| |
Collapse
|
9
|
Randomised trials of 6% tetrastarch (hydroxyethyl starch 130/0.4 or 0.42) for severe sepsis reporting mortality: systematic review and meta-analysis. Intensive Care Med 2013; 39:811-22. [PMID: 23430019 DOI: 10.1007/s00134-013-2863-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/26/2013] [Indexed: 01/04/2023]
Abstract
PURPOSE To assess the impact of 6% tetrastarch [hydroxyethyl starch (HES) 130/0.4 and 130/0.42] in severe sepsis patients. The primary outcome measure was 90-day mortality. METHODS A structured literature search was undertaken to identify prospective randomised controlled trials (RCTs) in adult patients with severe sepsis receiving 6% tetrastarch (of potato or waxy maize origin) as part of fluid resuscitation in comparison with other non-HES fluids after randomisation in the critical care setting. A systematic review and meta-analysis were performed. RESULTS Six RCTs were included (n = 3,033): three from 2012 (n = 2,913) had low risk of bias. Median tetrastarch exposure was 37.4 ml/kg (range 30-43 ml/kg). Ninety-day mortality was associated with tetrastarch exposure [relative risk (RR) 1.13; 95% confidence interval (CI) 1.02-1.25; p = 0.02] compared with crystalloid. The number needed to harm (NNH) was 28.8 (95 % CI 14.6-942.5). Publication bias and statistical heterogeneity (I(2) = 0%) were not present. Tetrastarch exposure was also associated with renal replacement therapy (p = 0.01; NNH 15.7) and allogeneic transfusion support (p = 0.001; NNH 9.9). No difference between groups was observed for 28-day mortality, for comparison with colloid as control, or for waxy maize-derived tetrastarch, but power was lacking. Overall mortality was associated with tetrastarch exposure (RR 1.13; 95% CI 1.02-1.25; p = 0.02). CONCLUSIONS In our analysis, 6% tetrastarch as part of initial fluid resuscitation for severe sepsis was associated with harm and, as alternatives exist, in our view should be avoided.
Collapse
|
10
|
Bellmann R, Feistritzer C, Wiedermann CJ. Effect of molecular weight and substitution on tissue uptake of hydroxyethyl starch: a meta-analysis of clinical studies. Clin Pharmacokinet 2012; 51:225-36. [PMID: 22420578 DOI: 10.2165/11594700-000000000-00000] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Intravenously infused hydroxyethyl starch (HES) can be found in urine, plasma and tissues. HES remaining in plasma and tissues is thought to increase the risk of clinical complications. HES solutions of lower molecular weight and substitution have been developed to increase urinary excretion and reduce plasma persistence. However, their effect on tissue uptake of HES has not been investigated in human subjects. OBJECTIVE Our objective was to test the hypothesis that lower molecular weight and substitution decrease tissue uptake of HES. DATA SOURCES Computer searches were performed of MEDLINE; EMBASE; the Cochrane Library; meeting abstract databases in surgery, anaesthesiology and intensive care; ClinicalTrials.gov; and Google. Supplementary sources were reference lists and electronic tables of journal contents. No time period or language restrictions were imposed. STUDY SELECTION Clinical studies were eligible for inclusion in the meta-analysis, if data were reported both for cumulative urinary excretion of HES over 24 hours after infusion and for plasma HES concentration at 24 hours. DATA EXTRACTION Data were extracted on 24-hour urinary excretion of HES, 24-hour HES plasma concentration, plasma volume, HES molecular weight and substitution, study design, type and demographics of subjects, indication for fluid infusion, and HES infusion regimen. Tissue uptake of HES was computed as the difference between the infused dose and the sum of urinary excretion and residual plasma HES at 24 hours. DATA SYNTHESIS Twenty-five clinical studies totalling 287 subjects were included. Tissue uptake of low-molecular-weight HES (≤200 kD) was 42.3% (95% confidence interval [CI] 39.6, 45.0) compared with 24.6% (CI 17.8, 31.4) for high-molecular-weight HES (p < 0.001). Similarly, tissue uptake of lower-substitution HES (≤0.5) was 42.4% (CI 39.5, 45.3) versus 26.6% (CI 19.6, 33.6) for higher-substitution HES (p < 0.001). Among the three most often investigated single HES solutions, tissue uptake of 130/0.4 (42.6%; CI 35.0, 50.2) and HES 200/0.5 (43.3%; CI 39.4, 47.2) closely coincided, whereas uptake of HES 450/0.7 (22.2%; CI 14.8, 29.6) was lower (p = 0.001 and p < 0.001, respectively). CONCLUSIONS This meta-analysis did not support the hypothesis that lower molecular weight and substitution decrease tissue uptake of HES. Further clinical studies of HES tissue uptake are needed.
Collapse
Affiliation(s)
- Romuald Bellmann
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | | | | |
Collapse
|
11
|
Stolzing A, Naaldijk Y, Fedorova V, Sethe S. Hydroxyethylstarch in cryopreservation - mechanisms, benefits and problems. Transfus Apher Sci 2012; 46:137-47. [PMID: 22349548 DOI: 10.1016/j.transci.2012.01.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 12/19/2011] [Accepted: 01/23/2012] [Indexed: 12/20/2022]
Abstract
As the progress of regenerative medicine places ever greater attention on cryopreservation of (stem) cells, tried and tested cryopreservation solutions deserve a second look. This article discusses the use of hydroxyethyl starch (HES) as a cryoprotectant. Charting carefully the recorded uses of HES as a cryoprotectant, in parallel to its further clinical use, indicates that some HES subtypes are a useful supplement to dimethysulfoxide (DMSO) in cryopreservation. However, we suggest that the most common admixture ratio of HES and DMSO in cryoprotectant solutions has been established by historical happenstance and requires further investigation and optimization.
Collapse
Affiliation(s)
- A Stolzing
- Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany.
| | | | | | | |
Collapse
|
12
|
Simon TP, Schuerholz T, Hüter L, Sasse M, Heyder F, Pfister W, Marx G. Impairment of renal function using hyperoncotic colloids in a two hit model of shock: a prospective randomized study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R16. [PMID: 22277099 PMCID: PMC3396252 DOI: 10.1186/cc11161] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 11/03/2011] [Accepted: 01/25/2012] [Indexed: 01/20/2023]
Abstract
Introduction One of the therapeutic essentials in severe sepsis and septic shock is an adequate fluid replacement to restore and maintain circulating plasma volume, improve organ perfusion and nutritive microcirculatory flow. The type of solution to be used as a fluid replacement remains under discussion. The aim of the study was to evaluate the effects of clinically used fluid replacement solutions on renal function and inflammatory response. Methods A total of 23 anesthetized and ventilated female German Landrace pigs were investigated over 19 hours using a two-hit model that combined hemorrhagic and septic shock. The septic shock was induced using an Escherichia coli laden clot placed into the abdominal cavity. Infusions of 6% hydroxyethylstarch 130/0.42 in acetate (6% HES 130), 4% gelatin in acetate (4% gelatin) and 10% hydroxyethylstarch 200/0.5 in saline (10% HES200) compared to Ringer's acetate (RAc) were used for fluid replacement to maintain a central venous pressure of 12 mmHg. Ringer's acetate was also used in the sham-treated group (SHAM). Results At study end the cardiac output (10% HES200 143 ± 48 ml/kgBW; 6% HES130 171 ± 47 ml/kgBW; RAc 137 ± 32 ml/kgBW; 4% gelatin 160 ± 42 ml/kgBW), as well as mean arterial pressure did not differ between groups. N-acetyl-beta-D-glucosamidase was significantly higher in the hydroxyethylstarch 200 (157 ± 115 U/g creatinine; P < 0.05) group compared to hydroxyethylstarch 130 (24 ± 9 U/g creatinine), Ringer's acetate (2 ± 3 U/g creatinine) and SHAM (21 ± 15 U/g creatinine) at the study's end. Creatinine significantly increased by 87 ± 84 percent of baseline in the 10% HES200 group compared to RAc and 6% HES130. We demonstrated in the histology of the kidneys a significant increase in osmotic-nephrosis like lesions for 4% gelatin compared to RAc, 6% HES130 and SHAM. Urine output was lowest in the 10% HES200 and 4% gelatin group, however not significantly. Interleukin(IL)-6 levels were significantly elevated in the 10% HES200 group (3,845 ± 1,472 pg/ml) two hours after sepsis induction compared to all other groups (6% HES130 1,492 ± 604 pg/ml; RAc 874 ± 363 pg/ml; 4% gelatin 1,623 ± 1,242 pg/ml). Conclusions Despite similar maintenance of macrocirculation 6% hydroxyethylstarch 130/0.42 and Ringer's acetate significantly preserve renal function and attenuate tubular damage better than 10% hydroxyethylstarch 200/0.5 in saline.
Collapse
Affiliation(s)
- Tim Philipp Simon
- Department of Intensive Care and Intermediate Care, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany.
| | | | | | | | | | | | | |
Collapse
|
13
|
Lange M, Ertmer C, Van Aken H, Westphal M. Intravascular Volume Therapy With Colloids in Cardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:847-55. [DOI: 10.1053/j.jvca.2010.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Indexed: 11/11/2022]
|
14
|
Hartog CS, Kohl M, Reinhart K. A systematic review of third-generation hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed. Anesth Analg 2011; 112:635-45. [PMID: 21304149 DOI: 10.1213/ane.0b013e31820ad607] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
Collapse
Affiliation(s)
- Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller University, Erlanger Allee 101, D-07747 Jena, Germany
| | | | | |
Collapse
|
15
|
Wittlinger M, Schläpfer M, De Conno E, Z'graggen BR, Reyes L, Booy C, Schimmer RC, Seifert B, Burmeister MA, Spahn DR, Beck-Schimmer B. The Effect of Hydroxyethyl Starches (HES 130/0.42 and HES 200/0.5) on Activated Renal Tubular Epithelial Cells. Anesth Analg 2010; 110:531-40. [DOI: 10.1213/ane.0b013e3181c03c97] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
16
|
CONTRA: Hydroxyethyl starch solutions are unsafe in critically ill patients. Intensive Care Med 2009; 35:1337-42. [DOI: 10.1007/s00134-009-1521-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 04/13/2009] [Indexed: 10/20/2022]
|
17
|
Ertmer C, Rehberg S, Van Aken H, Westphal M. Relevance of non-albumin colloids in intensive care medicine. Best Pract Res Clin Anaesthesiol 2009; 23:193-212. [PMID: 19653439 DOI: 10.1016/j.bpa.2008.11.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
18
|
Hartog C, Brunkhorst FM, Reinhart K. Old versus New Starches: What do We Know about their Differences? Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
19
|
Impact of Hydroxyethyl Starch on Renal Function. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
20
|
The role of tetrastarches for volume replacement in the perioperative setting. Curr Opin Anaesthesiol 2008; 21:674-8. [DOI: 10.1097/aco.0b013e32830dd073] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Haught JM, Jukic DM, English JC. Hydroxyethyl starch-induced pruritus relieved by a combination of menthol and camphor. J Am Acad Dermatol 2008; 59:151-3. [PMID: 18455262 DOI: 10.1016/j.jaad.2008.03.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 03/20/2008] [Accepted: 03/28/2008] [Indexed: 11/24/2022]
Abstract
Hydroxyethyl starch is a key component of many colloid volume expanders used in hypovolemic shock and otologic disease. Pruritus is a common side effect. Histopathology reveals multiple cytoplasmic vacuoles in dermal macrophages, endothelial cells, and perineural cells with electron-dense foreign material within the said vacuoles. Although classically refractory to treatment with corticosteroids and antihistamines, some benefit has been achieved with capsaicin, ultraviolet light therapy, and oral naltrexone. We present a case responsive to menthol and camphor and discuss the possible therapeutic mechanism.
Collapse
Affiliation(s)
- Justin M Haught
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
| | | | | |
Collapse
|
22
|
Ständer S, Evers S, Metze D, Schmelz M. Neurophysiological evidence for altered sensory function caused by storage of hydroxyethyl starch in cutaneous nerve fibres. Br J Dermatol 2005; 152:1085-6. [PMID: 15888187 DOI: 10.1111/j.1365-2133.2005.06573.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
23
|
Abstract
Hydroxyethyl starch (HES) is widely used for fluid management in broad populations of patients, particularly in the surgery and intensive care settings. Pruritus, often manifested as pruritic crises, is increasingly being recognized as a common major adverse effect of HES administration. This iatrogenic form of pruritus is frequently severe and protracted with a serious negative impact on patient quality of life, including sleep disturbance, disruption of daily routine and mental distress. Such pruritus is generally refractory to available therapies and can persist for up to 12-24 months. All currently clinically available HES solutions entail the risk of pruritus, including those of diverse molecular weights and substitutions. Although dose dependent, HES-induced pruritus nevertheless can often be provoked by relatively low routine doses. The pathophysiological basis for pruritus is the widespread tissue deposition of HES, prominently in macrophages. HES tissue deposits are long lasting and sometimes massive. Usually several weeks elapse between HES exposure and the onset of pruritus. Consequently, it is important to inquire about prior HES exposure in the diagnostic evaluation of pruritus sine materia. Awareness about the scope of the pruritus problem needs to increase among physicians administering HES. Well-designed clinical outcome studies are needed to assess more fully the incidence, dose dependency and mechanisms of pruritus with particular HES solutions.
Collapse
Affiliation(s)
- K Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany.
| |
Collapse
|
24
|
Weisshaar E, Ständer S, Metze D, Diepgen TL. [Hydroxyethyl starch-(HES)-induced pruritus as secondary complication of an occupational accident]. Hautarzt 2004; 55:558-61. [PMID: 15141295 DOI: 10.1007/s00105-004-0743-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 29-year old employee (controller in the textile industry) had an occupational accident leading to a femoral fracture. After surgery, he developed acute respiratory distress syndrome (ARDS) necessitating intensive care treatment. Three weeks after the accident, he developed generalized severe itching on a daily basis unresponsive to systemic and topical treatments. After one year, the itching had decreased to approximately 50% of its initial intensity. Hydroxyethyl starch (HES)-induced pruritus was diagnosed, based on the typical history and clinical features, the proven administration of HES and its cutaneous tissue storage by electron microscopy. Drug-induced pruritus caused by the plasma expander hydroxyethyl starch can be a secondary consequence of an occupational accident and thus an issue in accident compensation claims.
Collapse
Affiliation(s)
- E Weisshaar
- Abteilung Klinische Sozialmedizin, Berufs- und Umweltdermatologie, Universitätsklinikum Heidelberg, Heidelberg.
| | | | | | | |
Collapse
|
25
|
Leuschner J, Opitz J, Winkler A, Scharpf R, Bepperling F. Tissue storage of 14C-labelled hydroxyethyl starch (HES) 130/0.4 and HES 200/0.5 after repeated intravenous administration to rats. Drugs R D 2004; 4:331-8. [PMID: 14584961 DOI: 10.2165/00126839-200304060-00001] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE To investigate the effect of the molar substitution of hydroxyethyl starch (HES) solutions on tissue and organ storage in rats after repeated administration. STUDY DESIGN A controlled, multiple-dose study was performed in 48 rats. Daily bolus injections of 0.7 g/kg of 10% HES 130/0.4 or 10% HES 200/0.5 were administered on 18 consecutive days. In order to examine quantitatively the distribution and excretion of both preparations on HES tissue storage, radiolabelled HES was measured 3, 10, 24 and 52 days after the last administration. Tissue storage was expressed as percentage radioactivity of total administered HES dose in the total body, carcass, liver, kidney, spleen, lymph nodes, plasma and urine. RESULTS 52 days after the last administration the remaining radioactivity of labelled HES 200/0.5 was nearly 4-fold higher compared with HES 130/0.4 in the total body (2.45% vs 0.65% of the total administered dose). This difference in tissue storage was statistically significant (p < or = 0.01). A comparable difference was observed for the liver and carcass. CONCLUSION Tissue storage after repeated administration of an HES solution with a low molar substitution (0.4) was significantly lower in the total body as well as in the liver and carcass compared with an HES solution with a medium molar substitution (0.5). However, the potential clinical consequences of these present findings have not yet been determined.
Collapse
Affiliation(s)
- Jost Leuschner
- LPT Laboratory of Pharmacology and Toxicology, Hamburg, Germany
| | | | | | | | | |
Collapse
|
26
|
Abstract
Sepsis is associated with a profound intravascular fluid deficit due to vasodilatation, venous pooling and capillary leakage. Fluid therapy is aimed at restoration of intravascular volume status, haemodynamic stability and organ perfusion. Circulatory stability following fluid resuscitation is usually achieved in the septic patient at the expense of tissue oedema formation that may significantly influence vital organ function. The type of fluid therapy, crystalloid or colloid, in sepsis with capillary leakage remains an area of intensive and controversial discussion. The current understanding of the physiology of increased microvascular permeability in health and sepsis is incomplete. Furthermore, there is a lack of appropriate clinical study end-points for fluid resuscitation. This review considers critically the clinical and experimental data analysing the assessment of capillary leakage in sepsis and investigating the effects of different fluid types on increased microvascular permeability in sepsis.
Collapse
Affiliation(s)
- G Marx
- University of Liverpool, University Department of Anaesthesia, Liverpool, UK.
| |
Collapse
|
27
|
|