Use of hydroxyethyl starch in critically ill patients

We read with interest the article by Meybohm and colleagues regarding the use of hydroxyethyl starch (HES) in critically ill patients [1]. Although we may agree with their conclusion that the most important question is whether or not HES may be harmful, we cannot agree with their suggestion on further clinical use based only on strict indication for HES or a safety checklist. In recent major randomized trials, HES reversed hypovolemia and improved hemodynamic parameters earlier than crystalloids [2-4]. However, despite this physiologic benefit of HES, clinical results move in the opposite direction. Strong signals of a higher incidence of organ dysfunction or higher mortality in critically ill patients in large clinical trials cannot be disregarded [2,3,5]. Before going into further clinical trials or suggesting strict indications, we should first re-evaluate the effect of HES on experimental models. Unless a clear advantage of HES over crystalloid is demonstrated, which so far has not been, we must give the benefit of the doubt to the patients and not to the drug.