Hespan

[Aneroo]

Posting on behalf of my husband who works in the small little ICU/CCU at our local hospital:

How often do you use Hespan with patients who are in septic shock? He's noted that more boluses of NS and LR are used, and it wondering how the patients would do if Hespan were used more frequently instead.

Thanks!

[JeffTheRN]

In my experience, hespan has fallen out of use due to cost vs. benefit when compared to NS. Also, as PrettyinPink1234 mentions, coagulopathy and nephrotox are potential risks of use/overuse.

For our CCU, it comes in waves. Usually it is only the surgical residents that use it and very rarely at that. I assume it is not used often for the risks previously mentioned above and the fact that only a relatively small amount can be used for every 24h.

[Chisca, RN]

Hespan has polyvinyl chlorides which inhibits platelet aggregation.. If kidneys aren't working well or not at all these PVCs are not eliminated leading to coagulopathy. I think some doctors like it because it is a colloid and can expand intravascular volume. At least one intensivist who works here swears by it.

[research49]

Quick question. Where else, other than in the ICU, are fluids administered to treat patients in shock? ER? Second question--how do you usually assess patients' response? Many thanks.

[detroitdano]

Shock can happen anywhere. GPU patients can easily go into hypovolemic shock from poor I/O monitoring, and septic shock from, well, sepsis. Cardiogenic and neurogenic are another discussion for another day.

Hypovolemic shock is common in the OR. If your patient is bleeding out, has a HR of 130 and a BP of 70/40 then you probably need to be pounding in some fluids while fixing the problem.

Patient response would be improvement in vitals and tolerance of fluids (i.e. no crackles).

[research49]

Very helpful. A followup question. If you were able to monitor these patients' central blood pressure (the pressure in the ascending aorta) noninvasively, would that be valuable? Thanks, again.

[detroitdano]

If someone is so ill that they haven't responded to large amounts of fluid, an invasive BP measurement would be more appropriate for guiding treatment. If someone has gotten, say 3 liters of NS, and their NIBP is 100/60 up from 70/40 or so, going invasive would likely be inappropriate. Hope that answers your question.

[research49]

Thanks. A article was recently published in Intensive Care Medicine, Dufour et al. "Changes in pulse pressure following fluid loading, a comparison between aortic root(noninvasive tonometry and femoral arter (invasive recording) March 2011

The study found that the invasive and noninvasive measures of central pulse pressure, using arterial tonometry, were equivalent. This was a study of shock patients in the ICU, using central pulse pressure to assess patient response to fluid loading. I am trying to understand the range of possible clinical applications in-hospital for noninvasive central pressure (not brachial pressure) assessment.

Again, many thanks in advance to the group. All words of wisdom will be gratefully received.

[detroitdano]

Very cool. Found a discussion of the article through a quick search:

http://www.reuters.com/article/2011/03/29/idUS221466+29-Mar-2011+MW20110329

[esie]

One of the current trials being conducted by ANZICS Clinical Trials Group in Australia & New Zealand is the CHEST study. The study is comparing the use of Hydroxy-Ethyl Starch (Voluven, Hespian) 0.9% Sodium Chloride, with 0.9% Sodium Chloride alone, in fluid resuscitation in critically I'll adults over a 90 day mortality period. Having spoken to a couple of the Intensivists at my old unit, which is enrolled in the trial, the expected outcome is that this trial will have a similar outcome to the SAFE trial.*In the units I have worked in, generally only saline or albumin are used, although OT sometimes used Plasmalyte.

[badness]

we only use it in cabg's

[suanna]

Hespan usd to be our primary colloidal volume expander. Unfortunately for the makers of hetastarch, it picked up a "black box" warning from the FDA a few years ago about coagulopathy with use over 1500cc/24hrs. It was rare we ever gave that much, but with a bleeding patient is was possible in an emergancy we could have reached that level. We stopped using it for the fear that a bleeding patient would have a bad outcome and some ambulance chaser could point to the hespan and say " no wonder the patient bled to death- they gave hespan!- is causes coagulopathy" Even if the bleeding started before the hespan, even if they had less than the warned about amount, you can bet the fact that the bleeding didn't magicly stop was because of the hespan given to keep fluid in the vessels until a surgeon was on the scene.

Albumin is the new kid on the block. I have no idea what new "black box" warnings they are going to put on it, but I'm sure we'll have to find some other colloid to keep our patients alive with in a few more years.

Personaly, I think the solution to Americas health care crisis is 80% tort reform.- but that is for another thread....

[mmutk, BSN, RN, EMT-I]

We use Hespan on occasion for our post op CABGs, but if it doesn't work soon it's time to move on to the pressure...