Restricted to OR and Anesthesiology use only

Hetastarch 6% in lactated electrolyte injection (HLE) is an artificial colloid solution indicated for plasma volume expansion in the treatment of hypovolemia. HLE is not a blood or plasma substitute. Hetastarch is an oncotic agent which acts to retain fluid intravascularly until replacement by blood proteins occurs. This intravascular fluid retention is an advantage associated with the use of colloidal solutions in the treatment of circulatory shock.

A similar agent currently available on the formulary is hetastarch 6% in 0.9% normal saline injection (HespanÒ). HLE appears to be a safe and effective alternative to hetastarch 6% in 0.9% sodium chloride injection. According to several comparison studies, the use of HLE generally resulted in less need for intraoperative calcium supplementation, less estimated blood loss, and improved acid-base balance due to lactate buffer. Cost per 500 mL unit of Hextend is $23.73 (cost of hetastarch in 0.9% normal saline injection is $17.08 per 500 mL unit). The following table compares the components of HLE, hetastarch 6% in 0.9% sodium chloride injection, Lactated Ringer’s solution, and normal adult plasma.

COMPONENT	AMOUNT PER LITER
COMPONENT	Hetastarch 6% in lactated electrolyte inj (HextendÒ)	Hetastarch 6% in 0.9% sodium chloride inj (HespanÒ)	Lactated Ringer’s solution	Normal adult plasma
Hetastarch	60 g	60 g
Lactate	28 mEq		28 mEq
Dextrose	0.99 g			0.6-1.4 g
Sodium	143 mEq	154 mEq	130 mEq	134-149 mEq
Chloride	124 mEq	154 mEq	109 mEq	95-108 mEq
Calcium	5 mEq		2.7 mEq	2.24-2.46 mEq
Potassium	3 mEq		4 mEq	3.5-5.2 mEq
Magnesium	0.9 mEq			0.16-0.25 mEq

Product labeling indicates that the usual volume administered ranges from 500 – 1000 mL in adults, although volumes up to 1500 mL (20 mL/kg) per day have been administered without coadministration of blood or blood products. Volumes exceeding 1500 mL are generally infused with the coadministration of blood or blood products. Safety and efficacy of this product

Therapeutic parameters include monitoring of hemodynamic status to note changes in coagulation parameters, fluid balance, electrolyte concentrations, and acid-base balance. Bleeding time, clotting time, prothrombin time, partial thromboplastin time, complete blood count, and liver function tests should be monitored to assess toxicities.

Serious adverse reactions associated with hetastarch administration include rare hypersensitivity reactions, metabolic acidosis, circulatory overload, congestive heart failure, and pulmonary edema. Hematologic effects reported include intracranial bleeding, hemodilution-induced bleeding and/or anemia, Factor VIII deficiency, acquired von Willebrand’s-like syndrome, and coagulopathy, including disseminated intravascular coagulopathy and hemolysis.

Hetastarch administration is contraindicated in individuals with bleeding disorders, with congestive heart failure, or with hypersensitivity to hydroxyethyl starch. Individuals allergic to corn may also be allergic to hetastarch. Hetastarch should not be used in patients with renal disease exhibiting oliguria or anuria not associated with hypovolemia. Because HLE contains lactate, it should not be used in the treatment of lactic acidosis. Great care should be used with administration in patients with metabolic or respiratory alkalosis. In addition, HLE contains calcium and should not be infused with blood through the same administration set in order to avoid coagulation. Because potassium is a component of this product, great care should be used with its administration in patients with severe renal failure and hyperkalemia. Because HLE contains sodium, it should be used with caution in individuals with severe renal failure and congestive heart failure. HLE should not be used in leukapheresis. This agent does contain physiological levels of glucose, which may not be clinically significant, but should be a consideration when used in patients with subclinical or overt diabetes mellitus.

According to product labeling, HLE is pregnancy category C, and its excretion in human milk is not known.