Usefulness of hydroxyethyl starch (HES) as plasma expander

PICHON-RIVIERE A,; AUGUSTOVSKI, F; ALCARAZ A; BARDACH, ARIEL; FERRANTE, D; GARCIA MARTÍ, SEBASTIAN; GLUJOVSKY, D; LOPEZ, A; REGUEIRO, A

Se dispone del texto en papel

IECS

Año: 2006 p. 1 - 30

1668-2793

The aim of this overview is to assess the usefulness of hydroxyethyl starch (HES) in plasma expansion.A bibliographic search was carried out on the main databases (MEDLINE, Cochrane, DARE, NHS EED), in general Internet search engines, in health technology assessment agencies and health organizations. Priority was given to the inclusion of systematic revisions; controlled randomized clinical trials; health technology assessment reports and economic evaluations; clinical practice guidelines and coverage policies of other health systems. Information from local sources on the use of health resources, costs and coverage in Argentina was searched for.Colloids vs crystalloids: 4 systematic reviews were found on the subject. A Cochrane review Alderson et al included 37 studies comparing the different types of colloids and crystalloids in patients with shock. No statistically significant differences were found in both group's mortality. Another study published by Choi et al which included 814 patients showed no statistically significant differences in the mortality of both groups, except for the polytraumatized patient subgroup which showed a death RR of 0,39 (CI95% 0,17-0,89) which favored crystalloids. Neither differences were found in both groups in the systematic review published by Velanovich et al. In March 1998, a systematic review was published comparing resuscitation with colloids or crystalloids in critically ill patients. This study included 37 controlled randomized trials and showed a combined death RR of 1,29 (95% 0,94-1,77) with a trend to higher mortality in colloids and an increase in absolute risk of death of 4%. One study which compared HES vs jellies showed that 3,5% of patients who received HES presented a RR of 4 after transfusion without improvement in the plasma expansion parameters. Comparison against Albumin A systematic review published by Cochrane in 2004 showed a significant increase in the mortality of critical patients with burns treated with albumin and with a RR of 2,4 (1,11-5,29) and no difference in global mortality between both groups. In a trial conducted by Altman et al, no statistically significant differences were observed in clinical and laboratory parameters in cirrhotic patients receiving HES or Albumin except for a higher weight loss in the HES group. A study published by Boldt et al, assessed the effects of volume replacement with HES vs. albumin. No differences were found in mortality nor in hemodynamic parameters, consequently HES was proposed as a cheaper alternative than albumin.Adverse effects: The adverse effects (AE) related to the use of HES have been mainly abnormal clotting and kidney function disorders. HES solutions mainly differ in their physical and chemical features (Molecular weight and Substitution degree). These differences determine the AE. A multicenter controlled randomized trial conducted in France showed a RR of 1,82 for renal failure and a RR of 1,51 of oliguria in patients who received HES as compared to those treated with jelly. There were no statistically significant differences in mortality, probably due to the fact that patients were few. In August, 2003, the FDA recommended not to use HES in heart surgeries with extracorporeal circulation due to the increase in clotting and bleeding abnormalities. Wilkes et al conducted a meta-analysis which included 653 patients who received HES during cardiovascular surgeries. Those patients who received HES had more significant blood loss than those who received albumin. (33% vs 19%). Note that these adverse effects were observed in high molecular weight and high degrees of substitution HES. According to the review carried out by Boldt et al there should not be any contraindication for current HES (molecular weight 70-130 200 kd) and with low degree of substitution (0,4-0,5) in patients with kidney failure. Patients with kidney function impairment should use other types of expanders.The current cost according to the pharmaceutical handbook for the Voluven is $129,32 (Argentinean pesos November, 2005). Haemaccel, the widely used jelly, is $68 and albumin, $202,52.