Hydroxyethyl starches in the intensive care unit

Shortly after obtaining their market authorization, hydroxyethyl starches (HES) have emerged as the preferred fluid for resuscitation in many countries including France. Its natural origin and a lesser cost than that of albumin have promoted their large use. However, the benefit of colloids over crystalloids has never been demonstrated in the intensive care unit (ICU), and severe side-effects of HES have been rapidly described in humans. By reducing their molecular weight and substitution, the changing characteristics of the different HES generations shorted their intravascular half-life but did not improve the safety of the solutions. Several large randomized trials and meta-analyzes conclude on the renal toxicity of HES and even on a higher mortality in critically ill patients, independently of HES characteristics. These recent data have justified the reevaluation of the benefit-risk ratio of HES by the Food and Drug Administration and the European Medecines Agency. Their conclusions indicate that HES should not be used in critically ill patients. Since the first description of HES-related kidney damages, 20 years have been elapsed before prohibiting their use in the ICU. This literature review discusses the recently published evidences on the benefit-risk ratio of HES and the reasons that led to such a delay before health alert was triggered. We must learn from this experience.