Abstract
To the Editor In a recent paper describing the safety of modern starches, Van Der Linden et al.1 did not mention the consensus statement of the European Society of Intensive Care Medicine task force on colloid use in critically ill patients recommending against the use of 6% hydroxyethyl starch (HES) 130/0.4 in this population.2 Similarly, the authors failed to cite a 2011 Cochrane review cautioning against the routine administration of HES,3 as well as a systematic review by Gattas et al.4 concluding that “there is no convincing evidence that third-generation HES 130/0.4 is safe in surgical, emergency, or intensive care patients despite publication of numerous clinical studies.” Second, the recently published 7000-patient Crystalloid versus Hydroxyethyl Starch Trial5 showed that although there was no significant difference in 90-day mortality, patients randomized to HES 130/0.4 had more renal injury and requirement for renal-replacement therapy than those receiving saline. Third, we suggest that the authors may have left a falsely reassuring impression of the effects of HES 130/0.4 on coagulation. The coagulation studies included in their study were small trials comparing different synthetic colloids with HES 130/0.4. However, it is now known that HES 130/0.4 administration results in a weaker, smaller clot,6 a fact that might explain the increased transfusion rate in HES 130/0.4 treated individuals with blunt trauma compared with those treated with normal saline.7 Finally, we would like to point out that synthetic colloids do not always decrease tissue edema.8 This may be because Starling’s original model of semipermeable capillaries subject to hydrostatic and oncotic pressure differences is now known to be an oversimplification.9 In fact, an intact glycocalyx and lymphatic system are crucial to avoid tissue edema. Ehab Farag, MD, FRCA Maged Argalious, MD, MBA Jerome O’Hara, MD D. John Doyle, MD, PhD Department of General Anesthesiology Cleveland Clinic Cleveland, Ohio [email protected]
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