Resuscitation From Septic Shock With Capillary Leakage: Hydroxyethyl Starch (130 Kd), but Not Ringer’s Solution Maintains Plasma Volume and Systemic Oxygenation

Abstract

There is evidence suggesting that early fluid resuscitation is beneficial in the treatment of septic shock. The question as to which solution should be used remains controversial. Using a porcine septic shock model, we tested the effects of a new synthetic colloid hydroxyethyl starch (HES 130 kD) and a crystalloid regimen with Ringer's solution (RS) on plasma volume (PV) maintenance as well as on systemic and regional hemodynamics. Fourteen anaesthetized mechanically ventilated pigs received 0.75 g kg body weight of feces into the abdominal cavity to induce sepsis. They were randomly allocated to receive 6% HES 130 kD (n = 5) or RS (n = 5) and were compared with nonseptic controls receiving 6% HES 130 kD (n = 4). The infusion rate was titrated to maintain a central venous pressure of 12 mmHg. PV was determined by chromium-51-tagged erythrocytes and hematocrit. Albumin escape rate (AER) was calculated using iodine-125-labeled albumin. Arterio-intramucosal pCO2 gap, systemic hemodynamics, and oxygenation were obtained before and 6 h after induction of sepsis. AER increased in the HES (+38%) and RS groups (+38%) compared with control. PV was reduced in the RS group (-39%), but was maintained in the HES group (-1%). After 6 h of sepsis, HES 130 kD-treated animals had a significantly higher cardiac output (166 +/- 28 mL min kg vs. 90 +/- 18 mL min kg, P < 0.05), and a significantly higher mixed-venous oxygen saturation (65% +/- 8% vs. 40% +/- 14%, P < 0.05) than RS animals. In this porcine septic shock model with concomitant capillary leakage syndrome, resuscitation with HES 130 kD but not RS could maintain PV and preserve systemic hemodynamics and oxygenation.

Controversies in fluid therapy: Type, dose and toxicity

“…HES solutions have been shown to attenuate the acute inflammatory response [18][19][20][21] , mitigate endothelial barrier dysfunction and vascular leak [18,22] , and preserve intestinal barrier function [17] . Small clinical trials have suggested superiority of HES solutions for resuscitation of the microcirculation in sepsis [22] .…”

“…HES solutions have been shown to attenuate the acute inflammatory response [18][19][20][21] , mitigate endothelial barrier dysfunction and vascular leak [18,22] , and preserve intestinal barrier function [17] . Small clinical trials have suggested superiority of HES solutions for resuscitation of the microcirculation in sepsis [22] . Small randomized clinical trials have also shown that early fluid resuscitation with HES solutions results in more rapid hemodynamic stabilization and shock reversal (i.e., greater efficacy) compared with crystalloids, and require significantly less fluid to restore intravascular volume [23,24] .…”

Hydroxyethyl starch for fluid resuscitation in critically ill patients

“…1 Current state of the literature and study relevance Numerous experimental studies have provided a physiological rationale for the preferential use of a colloid over crystalloid therapy, with an emphasis on HES for resuscitation in septic shock and in states of acute stress (i.e., major trauma, perioperative). Hydroxyethyl starch solutions have been shown to attenuate the acute inflammatory response, 4-6 mitigate endothelial barrier dysfunction and vascular leak, 6,7 and preserve intestinal barrier function. 4 Small clinical trials have suggested HES solutions are also superior for resuscitation of the microcirculation in sepsis, 8 contribute to more rapid hemodynamic stabilization and shock reversal, and require significantly less fluid to restore intravascular volume.…”

Fluid Management in Sepsis: Colloids or Crystalloids?

“…1. Levels of plasma volume (PV) at baseline, and 6 h after induction of experimental sepsis in pigs [29]. RS: Ringer's solution; HES 130 kDa: 6 % hydroxyethyl starch 130/0.4.…”

“…Using our porcine septic shock model, we tested the effects of HES 130 kDa and a crystalloid regimen with Ringer's solution on plasma volume maintenance as well as on systemic hemodynamics [29]. We found that it was possible in the presence of marked capillary leakage not only to maintain plasma volume and COP by HES 130 kDa but also as a consequence to preserve systemic oxygenation and hemodynamics ( Fig.…”