Hetastarch (Hydroxyethyl Starch) is a starch derivative that is used as a volume expander in patients with hypovolemia, hypotension, and shock. It should be avoided in patients with liver and kidney disease and those who are critically ill.

Hetastarch (Hydroxyethyl Starch) Uses:

• Granulocyte yield increase (Hespan only):

  • It is indicated as an adjunct in leukapheresis. It improves harvesting and increases granulocytes yield by centrifugation.

• Plasma volume expansion:

  • It is indicated as volume expander in case of hypovolemia.

Hetastarch (Hydroxyethyl Starch) Dose in Adults

Granulocyte yield increase (Hespan):

• 250 - 700 mL

Note: Citrate anticoagulant is added before use and then the mixture is administered to the input line of the centrifuge apparatus.

Plasma volume expansion:

• IV: 500 - 1,000 mL or ~20 mL/kg once
• Can be repeated if required based on hemodynamics, and hydration status
• The maximum dose should not be more than 33 - 50 mL/kg/day, there is a risk of accumulation

Hetastarch (Hydroxyethyl Starch) Dose in Childrens

Note:

• Use crystalloid fluid first in case of severe dehydration.
• Give colloids according to hemodynamics, and hydration status.
• Do not use in critically ill patients, those undergoing open-heart surgery with cardiopulmonary bypass, or those with preexisting renal dysfunction, those undergoing open-heart surgery with cardiopulmonary bypass.
• According to Critical Care Medicine societies (ACCM, SCCM) use of hydroxyethyl starch (HES) solutions for fluid resuscitation of severe sepsis and septic shock in neonatal and pediatric patients

Volume expansion: Very limited data available: IV infusion:

• Children ≥1 year and Adolescents:

  • 10 mL/kg/dose

Pregnancy Risk Factor C

• Animal reproduction studies show adverse effects.

Hetastarch use during breastfeeding:

• Its presence in breast milk is not known.
• Use cautiously in lactating mother

Dose in Kidney Disease:

• Avoid in patients with preexisting renal disease
• Contraindicated if the patient has oliguria or anuria (not related to hypovolemia).

Dose in Liver disease:

• Mild to moderate impairment:

  • The manufacturer has not provided any adjustment in labeling. Use cautiously.

• Severe impairment:

  • Contraindicated in severe liver disease.

Side effects of Hetastarch (Hydroxyethyl Starch):

• Cardiovascular:

  • Bradycardia
  • Cardiac Failure
  • Increased Plasma Volume
  • Peripheral Edema
  • Tachycardia

• Central Nervous System:

  • Chills
  • Headache
  • Intracranial Hemorrhage

• Dermatologic:

  • Pruritus (Dose-Dependent; May Be Delayed)
  • Skin Rash

• Endocrine & Metabolic:

  • Hypervolemia
  • Increased Amylase (Transient)
  • Metabolic Acidosis (Hyperchloremic)

• Gastrointestinal:

  • Parotid Gland Enlargement
  • Vomiting

• Hematologic & Oncologic:

  • Anemia
  • Blood Coagulation Disorder (Factor VIII Deficiency, Acquired Von Willebrand's Like Syndrome, Dilutional Coagulopathy)
  • Disseminated Intravascular Coagulopathy (Rare)
  • Hemolysis (Rare)
  • Hemorrhage
  • Prolonged Bleeding Time
  • Prolonged Partial Thromboplastin Time
  • Prolonged Prothrombin Time
  • Thrombocytopenia
  • Wound Hemorrhage

• Hepatic:

  • Increased Serum Bilirubin (Indirect)

• Hypersensitivity:

  • Anaphylactoid Reaction
  • Hypersensitivity

• Neuromuscular & Skeletal:

  • Myalgia

• Respiratory:

  • Bronchospasm
  • Flu-Like Symptoms (Mild)
  • Non-Cardiogenic Pulmonary Edema

• Miscellaneous:

  • Fever

Contraindications to Hetastarch (Hydroxyethyl Starch):

• Hypersensitivity to hetastarch, or hydroxyethylstarch (HES), any component of the formulation
• Patients who are critically ill, such as
  • Sepsis
  • Grave liver disease
  • Renal disease with oliguria and anuria (not connected to hypovolemia).
  • Any fluid overload condition (eg pulmonary edema or heart failure).
  • Pre-existing bleeding or coagulation disorders

Hextend: Other contraindications

• Treatment for lactic acidosis
• leukapheresis

Warnings and precautions

• Anaphylactoid reactions

  • There have been reports of a variety anaphylactoid reactions, including death.
  • If the patient experiences hypersensitivity, discontinue immediately.
  • Hetastarch may cause allergic reactions in patients who are allergic to corn.

• Bleeding

  • Avoid using cardiac bypass pump prime while the patient is receiving cardiopulmonary bypass or shortly after.
  • These patients have experienced excessive bleeding from HES solutions. Monitor their coagulation status and discontinue any bleeding immediately.
  • If it is used for a prolonged period, it may cause a reversible, acquired von Willebrand syndrome or factor VIII deficiency.
  • It takes several days for coagulopathies to recover.
  • Intracranial bleeding and death were reported to prevent cerebral vasospasm from subarachnoid hemorhage.

• Fluid overload:

  • Fluid overload may result from its use
  • If the patient is at high risk for fluid overload, be cautious
  • Contraindicated for heart failure and other conditions that cause fluid overload

• Hematologic:

  • It can cause hemodilution, which may lead to a decrease in hemoglobin, coagulation factor and plasma proteins.
  • Monitor clinically for leukapheresis. Also, monitor with complete blood count (CBC) and PT/APTT.
  • It is possible to have impaired coagulation or a transient increase in bleeding time

• Hepatic impairment

  • You should be cautious if you have mild or moderate hepatic impairment
  • In severe hepatic impairment, contraindicated
  • Monitoring liver function.

• Renal impairment

  • Preexisting renal disease should be avoided. Contraindicated for patients with oliguria or anuria unrelated to hypovolemia
  • Monitor fluid status, urine output and infusion rate. Stop at the first sign that there is a renal injury.
  • If the patient has glomerular disease, it can raise the urine specific gravity.

• Thrombocytopenia:

  • Large volumes interfere with platelet function and temporarily prolong bleeding time
  • Avoid thrombocytopenia, as large volumes can interfere with platelet functions
  • It temporarily prolongs bleeding time.

Hetastarch (Hydroxyethyl starch; Hespan, Hextend): Drug Interaction

Monitoring parameters:

• Plasma volume expansion: Blood pressure, heart rate, capillary refill time, CVP, RAP, MAP, urine output
• if pulmonary artery catheter in place, monitor cardiac index, PCWP, SVR, and PVR
• Hemoglobin
• Hematocrit
• Serum electrolytes
• Renal function (continue to monitor for at least 90 days after administration)
• Acid-base balance
• Coagulation parameters
• Liver function tests

Granulocyte yield increase:

• CBC, total leukocyte and platelet counts, leukocyte differential count, hemoglobin, hematocrit, PT, PTT

How to administer Hetastarch (Hydroxyethyl Starch)?

• It is intended for Intravenous administration only;
• The rate of infusion depends upon various factors including the extent of blood loss, age, and clinical condition of the patient but, in general, should not be greater than 1.2 g/kg/hour (20 mL/kg/hour).
• The patient may develop a severe hypersensitivity reaction, Resuscitation equipment should be available
• It can be administered by pressure infusion, air should be removed from the bag before the infusion to avoid air embolism
• Avoid administration of Hextend with blood through the same transfusion set. Change IV tubing or flush with normal saline abundantly before administering blood through the same line.
• Replace IV tubing at least every 24 hours. Do not use if crystalline precipitates or is a turbid deep brown.

Granulocyte yield increase:

• Mix Hespan and citrate well. Administer to the input line of the centrifuge apparatus at a ratio of 1:8 to 1:13 to venous whole blood.

Mechanism of action of Hetastarch (Hydroxyethyl Starch):

It is a colloid starch structure that is used to produce volume expansion.

Duration:

• 3 - 36 hours

Excretion:

• It is mainly excreted in urine (~33% within 24 hours)

International Brand Names of Hetastarch:

• Hespan
• Hextend
• Elohaes
• Elohaest
• Farhes
• Haes Steril
• HAES-steril
• Haes-Steril
• Hemohes
• Hespander
• Hestar-200
• Hydroksyetyloskrobia
• Hyper HAES
• HyperHAES
• Hyperhes
• Infukoll HES
• Plasmasteril
• StarQuin
• Temo
• Widahes
• Widahes-130

Hetastarch  Brand Names in Pakistan: