Is it the end of the road for synthetic starches in critical illness?

In a linked paper (doi:10.1136/bmj.f839), Haase and colleagues report the findings of a systematic review and meta-analysis of recently completed large trials on the effects of a widely used formulation of synthetic hydroxyethyl starch.1 This work is a milestone in our drive to improve the care of critically ill patients.

Maintaining effective plasma volume is, perhaps, the most persistent challenge faced by clinicians who treat critically ill patients, in particular those with sepsis. In patients with sepsis, increased capillary permeability and loss of vascular tone cause loss of circulating plasma volume, which contributes to inadequate cardiac output and tissue perfusion. Crystalloid based intravenous replacement fluids rapidly escape the circulation, forcing clinicians to trade off the adverse effects of hypovolaemia against those of tissue oedema. One answer has been to administer colloid based intravenous fluids, which contain large molecules that are less likely to escape from leaky capillaries. In theory, this approach maintains plasma volume with administration of less fluid.

For four decades the merits of the varied colloid solutions including albumin, gelatins, and hydroxyethyl starches have been hotly debated. Of particular concern has been the increased risk of coagulopathy and acute kidney injury associated with the use of …