We read with great interest the review article of Dr. Kozek-Langenecker on the effects of hydroxyethyl starch (HES) solutions on hemostasis.1We agree with Dr. Kozek-Langenecker’s conclusion that rapidly degradable HES is favored for relatively beneficial low risk for hemostatic derangements, postoperative blood loss, and reoperation rates. We would like to add some considerations to the article’s recommendations.

First, Dr. Kozek-Langenecker’s practical recommendation that rapidly degradable HES is a suitable volume expander in the routine perioperative setting because of the adequate volume efficacy and the low risk of hemostatic derangement1may not be useful in the United States because rapidly degradable HES is not commercially available in the United States.

Second, at our level 1 trauma center, we still experience adverse reactions such as exacerbation of coagulopathy among injured patients despite the very restrictive use of slowly degradable HES. Therefore, the article’s recommendation to simply restrict usage of slowly degradable HES types whenever hemostatic competence is critical1may not be advisable.

Finally, the article admits that “in Europe, a large variety of HES products are commercially available but are dominated by rapidly degradable HES preparations, whereas slowly degradable HES preparations are mainly available in the United States.”1Notwithstanding the fact that Food and Drug Administration regulations and commercial marketability of HES are beyond the scope of the article, the editor would have significantly contributed to the article’s value if an editorial review has been devoted to the reasons why the availability and distribution of HES significantly differ between Europe and the United States. More importantly, now that the author has shown that rapidly degradable HES is better suited for trauma centers, the more important question becomes, What does it take to make rapidly degradable HES widely available in the United States? In addition, the publication of this article is worthy of both praise and criticism: praise for its in-depth explanation of HES’s effects on hemostasis, especially for indicating and contraindicating the use of both rapidly degradable and slowly degradable HES; and criticism for leaving the reader frustratingly in search of a rapidly degradable HES counterpart in the United States.

*University of California, San Francisco, California. tangj@anesthesia.ucsf.edu

Kozek-Langenecker SA: Effects of hydroxyethyl starch solutions on hemostasis. Anesthesiology 2005; 103:654–60