Hydroxyethyl starch or saline for fluid resuscitation in intensive care.
By J. Myburgh, S. Finfer, R. Bellomo, L. Billot, A. Cass, D. Gattas, P. Glass, J. Lipman, Bette Liu, C. McArthur and 4 more. New England Journal of Medicine, 2012
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BACKGROUND The safety and efficacy of hydroxyethyl starch (HES) for fluid resuscitation have not been fully evaluated, and adverse effects of HES on survival and renal function have been reported. METHODS We randomly assigned 7000 patients who had been admitted to an intensive care unit (ICU) in a 1:1 ratio to receive either 6% HES with a molecular weight of 130 kD and a molar substitution ratio of 0.4 (130/0.4, Voluven) in 0.9% sodium chloride or 0.9% sodium chloride (saline) for all fluid resuscitation until ICU discharge, death, or 90 days after randomization. The primary outcome was death within 90 days. Secondary outcomes included acute kidney injury and failure and treatment with renal-replacement therapy. RESULTS A total of 597 of 3315 patients (18.0%) in the HES group and 566 of 3336 (17.0%) in the saline group died (relative risk in the HES group, 1.06; 95% confidence interval [CI], 0.96 to 1.18; P=0.26). There was no significant difference in mortality in six predefined subgroups. Renal-replacement therapy was used in 235 of 3352 patients (7.0%) in the HES group and 196 of 3375 (5.8%) in the saline group (relative risk, 1.21; 95% CI, 1.00 to 1.45; P=0.04). In the HES and saline groups, renal injury occurred in 34.6% and 38.0% of patients, respectively (P=0.005), and renal failure occurred in 10.4% and 9.2% of patients, respectively (P=0.12). HES was associated with significantly more adverse events (5.3% vs. 2.8%, P<0.001). CONCLUSIONS In patients in the ICU, there was no significant difference in 90-day mortality between patients resuscitated with 6% HES (130/0.4) or saline. However, more patients who received resuscitation with HES were treated with renal-replacement therapy. (Funded by the National Health and Medical Research Council of Australia and others; CHEST ClinicalTrials.gov number, NCT00935168.).
Subfields: Critical Care and Intensive Care Medicine, Epidemiology, Nephrology
View Paper: https://www.semanticscholar.org/paper/55b453cefdcf9fc610ea58262479ff2a088a6b4b
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Citations in the corpus
- Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012 (2013, neutral): “(This recommendation is based on the results of the VISEP [128], CRYSTMAS [122], 6S [123], and CHEST [124] trials.”
- American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. (2018, result): “These findings in AP mirror recent studies in the critical care literature, which have not demonstrated a mortality benefit of HEScontaining fluids as resuscitative agents.(19)”
- Sepsis and septic shock. (2018, background): “52 56 Thus, given the increased expense associated with use of colloid fluids and the increased risk of nephrotoxicity (except with albumin, which does not increase this risk), 55 initial resuscitation should use crystalloid fluids.”
- KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. (2013, background): “In addition, we noted that there appears to be harm with starch-containing fluids.(32-36) Therefore, these solutions should be avoided in patients at risk of AKI or with AKI.”