[Limited applications for hydroxyethyl starch : background and alternative concepts]

Within the framework of a risk assessment procedure the Committee for Risk Assessment of Pharmacovigilance (PRAC) of the European Medicines Agency (EMA) came to the conclusion that the benefits of hydroxylethyl starch infusion solutions (HES) no longer outweighed the risks and on 14 June 2013 recommended that approval should be suspended. Until the procedure has finally been concluded, which could last several months, the Federal Institute for Drugs and Medical Products (BfArM) has recommended that HES should not be used.

The aim of this article is to present the data situation in the most objective and compact way and to ultimately give the reader the foundations in order to be able to form a personal opinion. In addition an attempt will be made to describe a concept how infusion therapy can be carried out without using hydroxyethyl starch (HES).

The background to this decision is given based on a review of the literature and the relevance for intensive care, emergency and perioperative medicine is assessed. Furthermore, a concept of infusion therapy without hydroxyethyl starch is formulated also based on the results of current studies.

For infusion regimens without HES it should be noted that gelatin represents a considerable risk for anaphylactic reactions, that transfer of the new variants of Creutzfeldt-Jacob disease (bovine spongiform encephalopathy BSE) cannot fundamentally be excluded and that some evidence has been found that gelatin can cause kidney injury, probably in a similar way to HES. With respect to the cost-benefit analysis of infusion solutions, blood loss in adults of approximately 1-1.5 l can be substituted by balanced crystalloids (basic therapy 4-5 times compared to the amount of blood lost). For larger blood losses small amounts of hyperoncotic albumin solution (20 %) or alternatively 5 % albumin solution can be used. The 20 % albumin solution seems to have some advantages because it has a higher volume effect (approximately 200 %) and can be more favourable for the fluid balance than 5 % albumin solution. Blood losses greater than 2-3 l normally also require administration of blood products (e.g. fresh frozen plasma FFP and erythrocyte concentrates EC).

The third generation HES solutions cannot be completely replaced by other colloids and in future crystalloids will more strongly again broadly form the basis for infusion therapy. In this aspect balanced crystalloids have priority with respect to the acid-base equilibrium. The history of HES has impressively shown that infusion therapy must be adjusted on a scientifically founded basis, whether in intensive care medicine, perioperative or emergency medicine. Large prospective studies with clinically relevant endpoints are urgently needed.