Large volume resuscitation with hydroxyethyl starch (HES) in lactated Ringer's (LR) solution restores perfusion, minimally induces hyperchloremia or impairs coagulation

Objective

To evaluate the impact of large volume (> 25 cc/kg bw) Hextend (HES in LR) resuscitation on perfusion, hyperchloremic metabolic acidosis and coagulation.

Methods

A convenience sample of ICU patients resuscitated by a single Intensivist at a University hospital using > 25 cc/kg bw of Hextend as part a resuscitation strategy was retrospectively examined. Patients were divided into three groups: trauma, sepsis, and post-op. IRB approved data included: age, sex, principal diagnosis, laboratory data, and fluid volumes. Successful resuscitation was defined as resolution of lactic acidemia. Data were divided into admission and 24 hour values and compared using a two-tailed, paired t-test. Data were compared using a t-test or chi-square; significance assumed for P < 0.05 (*).

Results

Patient mix was 54% trauma, 34% sepsis, and 12% postop. Of the trauma patients, 17% had traumatic brain injury, and 23% were receiving blood components on a massive transfusion protocol. All patients were mechanically ventilated and 26% were admitted with a coagulopathy. 36% of patients were admitted with a hyperchloremic metabolic acidosis. 78% of patients also had evidence of lactic acidosis on admission. 82% of trauma, 64% of sepsis, and 92% of post-op patients cleared their lactic acidemia by 24 hours. Mean HEX volumes were 38 ± 4 cc/kg bw (trauma), 31 ± 4 cc/kg bw (sepsis) and 27 ± 5 cc/kg bw (post-op). Chloride concentration remained unchanged no patients; decreased in 94%^* (trauma), 100% sepsis, and 100% post-op patients; and increased in 6%^* (trauma), 0% sepsis, and 0% post-op patients. PT/PTT remained unchanged in 0%^* (trauma), 90% sepsis, and 95% post-op patients; decreased in 97%^* (trauma), 7% sepsis, and 3% post-op patients; and increased in 3% (trauma), 3% sepsis, and 2% post-op patients. The mean pre-resuscitation pH was 7.24 ± 0.12 (trauma), 7.32 ± 0.09 (sepsis) and 7.35 ± 0.8 (post-op) while the mean pH at 24 hours was 7.36 ± 0.09^* (trauma), 7.37 ± 0.05 (sepsis), and 7.39 ± 0.08 (post-op).

Conclusions

Hextend may be used as part of a large volume resuscitation strategy in diverse patient populations including those with traumatic brain injury. Hextend helps minimize the hyperchloremia associated with massive volume resuscitation without significantly perturbing the serine protease dependent coagulation profile.