title: To use or not to use hydroxyethyl starch in intraoperative care: are we ready to answer the 'Gretchen question'?
abstract: OBJECTIVE
  The decision of the European Medicines Agency (EMA) against the use of hydroxyethyl starch (HES)-based volume replacement solutions in critically ill patients has led to a general uncertainty when dealing with HES-based solutions, even though HES-containing solutions can still be used for the treatment of hypovolaemia caused by acute (sudden) blood loss. This review discusses current evidence of the intraoperative use of HES-based solutions.
  
  
  RESULTS
  HES solutions are often criticized for possible side-effects on the kidney, the coagulation system or tissue storage. Relevant differences exist between modern 6% HES 130/0.4 and older generation of starches. Because of pathophysiological differences between elective surgery and critical illness, the evidence on renal injury and coagulation impairment with HES administration cannot be generalized. Current data suggest that there is no clinically relevant impact of 6% HES 130/0.4 administration on perioperative renal function and coagulation. Over-resuscitation is a frequent problem associated with adverse outcomes. Due to the higher volume effect, fluid overload with HES is probably more harmful than with crystalloids, whereas goal-directed use of HES may be able to reduce intraoperative fluid accumulation and overload.
  
  
  CONCLUSIONS
  The use of 6% HES 130/0.4 in elective surgery patients is associated with reduced fluid accumulation and no clinically relevant difference in bleeding or the rate of acute kidney injury as compared with crystalloid use alone. Current data do not allow a conclusion on mortality. As they provide no benefit, older starch preparations should not be used.
authors.affiliation: Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Heßler
authors.forename: Philip-Helge
authors.initials: PH
authors.lastname: Arnemann
authors.forename: Christian
authors.initials: C
authors.lastname: Ertmer
mesh_terms: D003422:Critical Care; D005440:Fluid Therapy / Q000379:methods; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000009:adverse effects / Q000627:therapeutic use*; D019990:Perioperative Care / Q000379:methods*; D010952:Plasma Substitutes / Q000627:therapeutic use*; D014882:Water-Electrolyte Balance
chemical_list: D006895:Hydroxyethyl Starch Derivatives; D010952:Plasma Substitutes