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differences in the inclusion of trial data regarding HES solutions , comparators and patient categories . The systematic reviews provide us with high-level evidence indicating that HES in general causes renal impairment as measured as increased use of renal replacement therapy and increased mortality . None of the systematic reviews found evidence to support the notion that tetrastarch has a better safety profile than other HES solutions . In fact , the two largest trials ( CHEST and the 6S trial ) compared tetrastarch to crystalloid solutions and found increased use of renal replacement therapy and even increased mortality in one trial ( the 6S trial ). 3 , 4
The results of the Colloids Compared to Crystalloids in Fluid Resuscitation of Critically Ill Patients ( CRISTAL ) trial were published in 2013 . 11 In this trial , ICU patients with shock were randomised to open-labelled resuscitation with HES 130 , albumin or gelatin versus any crystalloid solution .
HES in peri- and postoperative care In general , trials of tetrastarch in surgery are relatively small , with short-term follow-up only and high risk of bias . 9 , 12 Therefore , these trials cannot inform us about effects and side-effects of HES beyond the first few days . After the retraction of the trials by Boldt , there are only few trials comparing the potency of tetrastarch versus crystalloid in the surgical setting . Therefore , the potency difference remains largely unknown .
As the harmful effects of HES may occur late , at least in patients with sepsis , 3 , 13 the lack of long-term safety data on tetrastarch in surgery is a dilemma for the clinicians who continue to use HES in these patients . Even though acute kidney injury is unlikely in low-risk patients , it is problematic that the rate and severity of itching is unknown after the use of tetrastarch in patients undergoing elective surgery . There are updated systematic reviews on the use of tetrastarch in surgical patients , 14 , 15 but these included healthy persons and trials with other HES solutions as comparator hampering the interpretation of the results . In addition , the recommendations of the Cochrane Collaboration were not followed in these reviews and they were sponsored by industry , both of which increase the risk of bias . hydrolysis of collagen , most often from cattle bone . The products are now modified by urea cross-linking or succinylation . The gelatins used in fluid therapy have a molecular weight around 20 kDa with a wide range and are excreted by the kidneys without prior metabolism . Gelatins have lower molecular weight than both HES and albumin , but there are no highquality trial data showing gelatins potency as plasma expander compared to crystalloids .
Overall , the evidence for the use of gelatin is poor and no large , randomised trials have been performed to assess the efficacy and harm of this class of colloid . A recent systematic review identified that the trials comparing gelatin with crystalloid or albumin solutions were small , done in elective surgery mainly , and had follow-up time of less than 24h . 16 The side-effects of gelatin are comparable to those observed with HES , including impairment of kidney function and haemostasis . Thus , overall beneficial effects of gelatin are unlikely in critically ill patients , a notion supported by data from a meta-analysis 15 and from a before-and-after study in a single ICU . 17 In the latter study , gelatin was associated with acute kidney injury in patients with severe sepsis . In line with this , the European Society of Intensive Care Medicine ( ESICM ) Task Force on colloids recommended that gelatin is only used in the context of randomised clinical trials . 6
Conclusions The evidence to support that resuscitation with colloids may result in less fluid use and improved haemodynamics is sparse . In contrast , it is clear from several high-quality trials and meta-analyses in critically ill patients that treatment with tetrastarches causes impaired renal function and haemostasis and may even increase mortality . Therefore , HES should not be used in these patients . Gelatin is considerably less studied , but the overall effects of colloids are likely to be minor compared to crystalloids and the side-effects of gelatins comparable to starch . Following this , the use of synthetic colloids should be limited in all patient categories .
Gelatin Compared to HES , gelatin was used less frequently in the worldwide point prevalence study . 1 In some countries , such as the UK and Hong Hong , gelatin was the most frequently used colloid .
The gelatins are polypeptides produced by
References 1 Finfer S et al . Resuscitation fluid use in critically ill adults : an international cross-sectional study in 391 intensive care units . Crit Care 2010 ; 14 : R185 . 2 Finfer S et al . A comparison of albumin and saline for fluid resuscitation in the intensive care unit . N Engl J Med 2004 ; 350:2247 – 56 . 3 Perner A et al . Hydroxyethyl starch 130 / 0.42 versus Ringer ’ s acetate in severe sepsis . N Engl J Med 2012 ; 367:124 – 34 . 4 Myburgh JA et al . Hydroxyethyl starch or saline for fluid resuscitation in intensive care . N Engl J Med 2012 ; 367:1901 – 11 . 5 Bellmann R , Feistritzer C , Wiedermann CJ . Effect of molecular weight and substitution on tissue uptake of hydroxyethyl starch : a metaanalysis of clinical studies . Clin Pharmacokinet 2012 ; 51:225 – 36 .
6 Reinhart K et al . Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients . Intensive Care Med 2012 ; 38:368 – 83 . 7 Perel P , Roberts I , Ker K . Colloids versus crystalloids for fluid resuscitation in critically ill patients . Cochrane Database Syst Rev 2013 ; 2 : CD000567 . 8 Zarychanski R et al . 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 – 88 . 9 Gattas DJ et al . Fluid resuscitation with 6 % hydroxyethyl starch ( 130 / 0.4 and 130 / 0.42 ) in acutely ill patients : systematic review of effects on mortality and treatment with renal replacement therapy . Intens Care Med 2013 ; 39:558 – 68 .
10 Haase N et al . 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 . 11 Annane D et al . Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock : the CRISTAL randomized trial . JAMA 2013 ; 310:1809 – 17 . 12 Hartog CS , Kohl M , Reinhart K . A systematic review of thirdgeneration hydroxyethyl starch ( HES 130 / 0.4 ) in resuscitation : safety not adequately addressed . Anesth Analg 2011 ; 112:635 – 45 . 13 Brunkhorst FM et al . Intensive insulin therapy and pentastarch resuscitation in severe sepsis . N Engl J Med 2008 ; 358:125 – 39 . 14 Van der Linden P et al . Safety of modern starches used
during surgery . Anesth Analg 2013 ; 116:35 – 48 . 15 Martin C et al . Effect of waxy maize-derived hydroxyethyl starch 130 / 0.4 on renal function in surgical patients . Anesthesiology 2013 ; 118:387 – 94 . 16 Thomas-Rueddel DO et al . Safety of gelatin for volume resuscitation – a systematic review and metaanalysis . Intensive Care Med 2012 ; 38:1134 – 42 . 17 Bayer O et al Effects of fluid resuscitation with synthetic colloids or crystalloids alone on shock reversal , fluid balance , and patient outcomes in patients with severe sepsis : a prospective sequential analysis . Crit Care Med 2012 ; 40:2543 – 51 .
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