Assessment of hemodynamic efficacy and safety of 6% hydroxyethyl starch 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: how to guide fluid therapy?

Abstract

We argue that assessing the hemodynamic effi cacy of hydroxyethyl starch (HES) versus NaCl in patients with severe sepsis requires an algorithm to direct the timing and amount of fl uid resuscitation. Such an algorithm may include hemodynamic fl ow parameters. In a recent issue of Critical Care, Guidet and colleagues [1] reported that a smaller amount of 6% HES 130/0.4 versus 0.9% NaCl was required to achieve hemodynamic stability (HDS) during the initial phase of fl uid resuscitation in patients with severe sepsis. Th e target parameters indicating HDS included central venous pressure (CVP) (8 to 12 mm Hg), a poor indicator of fl uid responsiveness [2], and a large urine output (>2 mL/kg per hour), and therefore pose a risk of over-infusion. Other authors have reported that over-infusion, elevated CVP, and excessive fl uid resuscitation with HES are associated with increased mortality in patients with sepsis [3,4]. In contrast, after initial HDS was achieved, no such target parameters were defi ned, and so the cumulative volumes of study drug infused over the course of four consecutive days in the intensive care unit (ICU) were similar for the HES (2,615 mL) and NaCl (2,788 mL) groups. No diff erences in mortality, hospital length of stay, or kidney function were found. Th is study may be showing only that, in the absence of an algorithm to guide fl uid resuscitation, intensivists use an unvarying amount of fl uids, but it is impossible to know whether these fl uids were, in fact, indicated. In patients undergoing major abdominal surgery, hemodynamic algorithms that guide the timing and amount of fl uid administration have helped determine the clinical effi cacy of fl uid therapy [5]. Th e negative results reported by Guidet and colleagues suggest that hemodynamic algorithms for patients with sepsis are urgently required to accurately compare the hemodynamic effi cacy, safety, and outcome of HES versus NaCl fl uid replacement.