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HES: time to change my mind?

  • Guenther Frank
From the Inside

I very well remember the presentation of Konrad Reinhart at the ESICM Lives Congress 2011 in Berlin about the recommendations of the task force on colloid volume therapy in critically ill patients, which were later published in this journal [1]. I was a believer and the consumption of HES in my anesthesia department in Eisenstadt Austria went down to a minimum over the next year and we abandoned any synthetic colloid and stopped using HES, not only in the ICU but also in anesthesia and in emergency medicine including obstetrics and trauma care. Since this is a radical decision, I followed the discussion about HES very carefully over the last years. Large trials were carried out and published and heavily criticized. On December 19th, 2013, the European Medicines Agency published a decision of the European Commission that HES solutions must no longer be used to treat patients with sepsis or burn injuries or critically ill patients, because of an increased risk of kidney injury and mortality, but HES wiould be available in restricted patient populations. Manufacturers were forced to include contraindications and warnings in the drug information. Usage of HES further went down and the discussion cooled down. Now in January 2018, PRAC and EMA started a new initiative to suspend the licence of HES in the EU, and the discussion started again [2].

Over the last 4 years, I changed hospitals two times and tried to convince my new colleagues to use HES with caution and to follow the recommendations of the EMA. My impression about HES usage in the clinical setting is that it depends more on the attitude of the physician to HES than on the medical circumstances how often, when and how much HES is used. In Austria, pharmaceutical companies are still promoting HES heavily. EMA stated in 2018 that results from two drug utilisation studies were indicating that HES solutions are being used in critically ill patients and those with sepsis and kidney injury, despite restrictions introduced in 2013. The studies are unfortunately not mentioned, but my experiences affirm this statement.

And now in early 2018, a further very well carried out trial has been published which may change my mind [3]. HES may have an advantage in elective major abdominal surgery, especially in avoiding interstitial edema and anastomotic leakage. HES-yes or HES-no may not be the answer. What I have learned from the now 420 citations in my endnote library concerning volume replacement and fluid management, and my experience with and without HES, is that there is one reason to use HES and two reasons not to do so. The one reason to use it is that it remains intravascularly if the endothelial barrier including the glycocalyx stays intact and therefore has a more enhanced effect on plasma volume and causes less edema than crystalloids. The two reasons not to use it are the potentially negative effects on kidney function [4] and coagulation [5], both of which are dose-dependent. It is not easy to find the balance between risks and benefits, but lately, when I think that capillary leakage occurs or when coagulation is compromised, it is time to stop using HES. It would be helpful to have an early bedside marker for capillary leakage, but meanwhile we must consider situations when glycocalyx may be destroyed [6] not appropriate to use HES. In addition to sepsis and burns, these are anaphylaxis, cardiopulmonary resuscitation, hemorrhagic shock, and others [7].

I have tried for many years now to avoid synthetic colloids completely and I really do not miss them. But I am still not quite sure whether there may be some benefit in elective major abdominal surgery. I will continue to follow the scientific discussion and may change my mind, as every clinician should do sometimes.

Notes

Compliance with ethical standards

Conflicts of interest

Guenther Frank declares that he has no conflicts of interest.

References

  1. 1.
    Reinhart K, Perner A, Sprung CL, Jaeschke R, Schortgen F, Johan Groeneveld AB, Beale R, Hartog CS (2012) Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients. Intensive Care Med 38:368–383CrossRefPubMedGoogle Scholar
  2. 2.
    Annane D, Fuchs-Buder T, Zoellner C, Kaukonen M, Scheeren TWL (2018) EMA recommendation to suspend HES is hazardous. Lancet 391:736–738CrossRefPubMedGoogle Scholar
  3. 3.
    Joosten A, Delaporte A, Ickx B, Touihri K, Stany I, Barvais L, Van Obbergh L, Loi P, Rinehart J, Cannesson M, Van der Linden P (2018) Crystalloid versus colloid for intraoperative goal-directed fluid therapy using a closed-loop system: a randomized, double-blinded, controlled trial in major abdominal surgery. Anesthesiology 128:55–66CrossRefPubMedGoogle Scholar
  4. 4.
    Neuhaus W, Schick MA, Bruno RR, Schneiker B, Förster CY, Roewer N, Wunder C (2012) The effects of colloid solutions on renal proximal tubular cells in vitro. Anesth Analg 114:371–374CrossRefPubMedGoogle Scholar
  5. 5.
    Schlimp CJ, Cadamuro J, Solomon C, Redl H, Schöchl H (2013) The effect of fibrinogen concentrate and factor XIII on thromboelastometry in 33% diluted blood with albumin, gelatine, hydroxyethyl starch or saline in vitro. Blood Transfus 11:510–517PubMedPubMedCentralGoogle Scholar
  6. 6.
    Chappell D, Jacob M, Becker BF, Hofmann-Kiefer K, Conzen P, Rehm M (2008) Expedition glycocalyx. A newly discovered “Great Barrier Reef”. Anaesthesist 57:959–969CrossRefPubMedGoogle Scholar
  7. 7.
    Schött U, Solomon C, Fries D, Bentzer P (2016) The endothelial glycocalyx and its disruption, protection and regeneration: a narrative review. Scand J Trauma Resusc Emerg Med 24:48CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

Authors and Affiliations

  1. 1.Department of Anaesthesiology and Intensive Care MedicineHospital HornHornAustria

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