The Place for Starches and Other Colloids

This chapter provides a comprehensive review of synthetic colloids, specifically hydroxyethyl starch (HES) solutions, and their role in resuscitation of critically ill, perioperative, and trauma patients. This chapter addresses various questions, including the crystalloid versus colloid debate, the strengths and weaknesses of different fluid trials and meta-analyses, and the specific situations or patient groups where colloids may have an advantage. This chapter focuses on the results of five major trials that compare the use of crystalloids versus colloids in critically ill patients. The 6S study and the CHEST trial confirmed the suspicion of renal damage associated with HES solutions, and the European Medicines Agency’s (EMA) safety committee prohibited the use of HES solutions in critically ill, septic, and burn patients, or those with kidney injury in 2013. However, many questions and controversies remained thereafter and more recently the European Commission has suspended the marketing authorizations of HES solutions for infusion. The use of HES and other synthetic colloids should be restricted to resuscitation in the perioperative setting or in limited volumes with extreme caution in trauma settings outside of the EU. The take-home messages include the availability of natural and synthetic colloids, the lack of outcome benefit in clinical trials, the association of HES with renal failure and increased use of renal replacement therapy, and the unsafe use of synthetic colloids in perioperative patients. This chapter recommends limiting the dose of synthetic colloids to 30ml/kg when given in the peri- and postoperative phase.