(HET a starch)
- HES 450/0.7
- Hydroxyethyl Starch
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Hespan: 6% (500 mL)
Hextend: 6% (500 mL)
Generic: 6% (500 mL)
Brand Names: U.S.
- Plasma Volume Expander, Colloid
Produces plasma volume expansion by virtue of its highly colloidal starch structure
Urine (33% to 40% within 24 hours); smaller molecular weight molecules (<50,000 daltons) rapidly excreted
Duration of Action
Use: Labeled Indications
Granulocyte yield increase (Hespan): Used as an adjunct in leukapheresis to improve harvesting and increase the yield of granulocytes by centrifugation
Hypovolemia: Blood volume expander used in treatment of hypovolemia
Hypersensitivity to hydroxyethyl starch or any component of the formulation; renal failure with oliguria or anuria (not related to hypovolemia); any fluid overload condition (eg, pulmonary edema, congestive heart failure); pre-existing coagulation or bleeding disorders; critically ill adult patients, including patients with sepsis, due to increased risk of mortality and renal replacement therapy; severe liver disease
Hextend is also contraindicated in the treatment of lactic acidosis and in leukapheresis
Plasma volume expansion: IV: 500-1000 mL (up to 1500 mL daily) or 20 mL/kg/day (up to 1500 mL daily). Note: With severe dehydration, administer crystalloid first. Daily dose and rate of infusion dependent on amount of blood lost, on maintenance or restoration of hemodynamics, and on amount of hemodilution. Titrate to individual colloid needs, hemodynamics, and hydration status. Do not use in the critically ill, those undergoing open heart surgery and cardiopulmonary bypass, or those with preexisting renal dysfunction.
Leukapheresis (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.
Refer to adult dosing.
Dosing: Renal Impairment
Avoid use in patients with pre-existing renal dysfunction. Use is contraindicated in renal failure with oliguria or anuria (not related to hypovolemia). Discontinue use at the first sign of renal injury.
Dosing: Hepatic Impairment
No dosage adjustment provided in manufacturer’s labeling; use with caution.
Do not use if crystalline precipitate forms or is turbid deep brown.
Volume expansion: Administer IV only; may be administered via infusion pump or pressure infusion. Administration rates vary depending upon the extent of blood loss, age, and clinical condition of patient but, in general, should not exceed 1.2 g/kg/hour (20 mL/kg/hour); however, rates up to 1000 mL over 7-8 minutes via pressure infusion have been studied in otherwise healthy subjects (McIlroy, 2003). Anaphylactoid reactions can occur, have epinephrine and resuscitative equipment available. If administered by pressure infusion, air should be withdrawn or expelled from bag prior to infusion to prevent air embolus. Do not administer Hextend with blood through the same administration set. Change IV tubing or flush copiously with normal saline before administering blood through the same line. Change IV tubing at least every 24 hours.
Leukapheresis: 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.
Stable in NS.
Y-site administration: Incompatible with amikacin, cefotaxime, cefoxitin, gentamicin, theophylline, tobramycin.
Y-site administration: Incompatible: with amphotericin B, diazepam, sodium bicarbonate.
Store at 25°C (77°F); avoid excessive heat; do not freeze. Brief exposure up to 40°C (104°F) does not adversely affect the product. Do not use if crystalline precipitate forms or is turbid deep brown. In leukapheresis, admixtures of 500-560 mL of Hespan with citrate concentrations up to 2.5% are compatible for 24 hours.
Arbekacin: Hetastarch may enhance the nephrotoxic effect of Arbekacin. Avoid combination
Serum amylase levels may be temporarily elevated following administration; could interfere with the diagnosis of pancreatitis.
Large hetastarch volumes may result in decreased coagulation factors, plasma proteins, and /or hematocrit due to dilutional effect.
Frequency not defined.
Cardiovascular: Bradycardia, cardiac failure, circulatory overload, increased plasma volume, peripheral edema, tachycardia
Central nervous system: Chills, headache, intracranial hemorrhage
Dermatologic: Pruritus (dose dependent; may be delayed), skin rash
Endocrine & metabolic: Increased amylase (transient), metabolic acidosis
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
Postmarketing and/or case reports (Limited to important or life-threatening): Angioedema, cough, erythema multiforme, facial edema, hypotension, laryngeal edema, periorbital edema, renal insufficiency, severe hypotension, stridor, submaxillary gland enlargement, tachypnea, urticaria, ventricular fibrillation
Concerns related to adverse effects:
• Anaphylactoid reactions: Anaphylactic/anaphylactoid reactions have been reported; discontinue use immediately with signs of hypersensitivity and administer appropriate therapy. Patients allergic to corn may be allergic to hetastarch.
• Bleeding: Not recommended for use as a cardiac bypass pump prime, while the patient is on cardiopulmonary bypass, or in the period immediately afterward. HES solutions have been associated with excess bleeding in these patients. Monitor the coagulation status in patients undergoing open heart surgery in association with cardiopulmonary bypass. Discontinue use of HES at the first sign of coagulopathy. May cause coagulation abnormalities in conjunction with a reversible, acquired von Willebrands-like syndrome and/or factor VIII deficiency when used over a period of days. Consider replacement therapy if a severe factor VIII deficiency is detected. Coagulopathies may take several days to resolve. When used to prevent cerebral vasospasm in patients with subarachnoid hemorrhage (off-label use), significant clinical bleeding, intracranial bleeding and death have been reported.
• Fluid overload: Administration may cause fluid overload; use with caution in patients at risk from overexpansion of blood volume (eg, very young, elderly patients); use is contraindicated in heart failure or any pre-existing condition where volume overload is a potential concern.
• Hematologic: Large volumes of hetastarch may cause a reduction in hemoglobin concentration, coagulation factors, and other plasma proteins due to hemodilution; when used for leukapheresis, frequent clinical evaluation and complete blood counts (CBC) are recommended. If leukapheresis frequency is greater than whole blood donation guidelines, consider monitoring total leukocyte and platelet counts, leukocyte differential, PT, and PTT as well. Coagulation may be impaired (eg, prolonged PT, PTT, and clotting times) and a transient prolongation of bleeding time may be observed.
• Hepatic effects: Monitor liver function at baseline and periodically during treatment.
• Hepatic impairment: Use with caution in patients with hepatic impairment. Monitor liver function at baseline and periodically during treatment. Use is contraindicated in patients with severe liver disease; may result in further reduction of coagulation factors, increasing the risk of bleeding.
• Renal impairment: Avoid use in patients with preexisting renal impairment; monitor fluid status, urine output, and infusion rate; discontinue use at the first sign of renal injury. Larger hetastarch molecules may leak into urine in patients with glomerular damage; may elevate urine specific gravity. Use is contraindicated with oliguria or anuria not related to hypovolemia.
• Thrombocytopenia: Use with caution in patients with thrombocytopenia; large volumes may interfere with platelet function and transiently prolong bleeding time. Observe for bleeding.
• Critically-ill patients: [U.S. Boxed Warning]: HES solutions have been associated with mortality and renal injury requiring renal replacement therapy in critically-ill patients, including patients with sepsis; avoid use in critically-ill adult patients, including those with sepsis. Use should also be avoided in patients admitted to the ICU (Brunkhorst, 2008; Perel, 2011; Perner, 2012; Zarychanski, 2009). The Society of Critical Care Medicine (SCCM) also recommends against the use of HES solutions for fluid resuscitation of severe sepsis and septic shock; crystalloids (eg, sodium chloride) are recommended instead (Dellinger, 2013). If used in patients who are not critically ill, avoid use in patients with pre-existing renal dysfunction and discontinue use at the first sign of renal injury. Since the need for renal replacement therapy has been reported up to 90 days after HES administration, continue to monitor renal function in all patients for at least 90 days.
Dosage form specific issues:
• Hextend: Contains calcium, lactate and potassium; use with caution in situations where electrolyte and/or acid-base disturbances may be exacerbated (renal impairment, respiratory alkalosis, metabolic alkalosis). Do not use in leukapheresis.
• Appropriate use: Not a substitute for red blood cells or coagulation factors.
• Laboratory test interference: May cause temporarily elevated serum amylase levels and interfere with pancreatitis diagnosis. Dilutional effects (particularly with high doses) can cause decreased plasma proteins (including coagulation factors) and a decreased hematocrit.
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
Leukapheresis: CBC, total leukocyte and platelet counts, leukocyte differential count, hemoglobin, hematocrit, PT, PTT
Pregnancy Risk Factor
Adverse events have been observed in some animal reproduction studies.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Have patient report immediately to prescriber signs of kidney problems (urinary retention, blood in urine, change in amount of urine passed, or weight gain), shortness of breath, excessive weight gain, swelling of arms or legs, bruising, bleeding, tachycardia, bradycardia, or arrhythmia (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.