Hextend
Hetastarch 6 percent in lactated electrolyte solution
Brand names:Hextend
A synthetic colloid solution of 6 percent hetastarch in a balanced electrolyte vehicle, used historically as a TCCC volume expander for hemorrhagic shock. Hextend was a TCCC standard from approximately 2003 to 2018; it has since been removed from primary TCCC doctrine due to evidence of harm in critically ill patients. Current TCCC favors blood products for resuscitation when available. Hextend remains in some legacy kits and certain austere scenarios.
Pharmacology and Actions
Hetastarch is a high-molecular-weight starch derivative that produces colloid oncotic pressure, drawing fluid into the intravascular space and producing more sustained volume expansion than crystalloids. The colloid effect provides approximately 100 percent volume expansion (vs 25 percent for crystalloids) with longer intravascular retention. The balanced electrolyte vehicle includes physiologic levels of sodium, chloride, potassium, calcium, magnesium, and lactate as a buffer precursor. The drug expands intravascular volume rapidly without the large volumes of crystalloid required for equivalent effect.
Indications
- Hemorrhagic shock when blood products are not available (historical TCCC use)
- Volume resuscitation in austere or prolonged casualty care environments without blood
- Limited current TCCC role; superseded by blood products and balanced crystalloid in current doctrine
Absolute Contraindications
- Sepsis or septic shock (FDA black box warning: increased mortality)
- Severe renal impairment or pre-existing renal disease
- Bleeding disorders or coagulopathy
- Liver disease
- Critically ill patients (FDA black box warning: increased mortality)
- Volume overload conditions
- Known hetastarch or starch allergy
Precautions and Side Effects
FDA issued black box warnings for hetastarch products in 2013 based on evidence of increased mortality and renal replacement therapy requirements in critically ill patients. Acute kidney injury is the major concern with hetastarch use. Coagulopathy and bleeding can be worsened by hetastarch through dilutional effect and direct inhibition of factor VIII and von Willebrand factor. Anaphylactoid reactions can occur. Pruritus may develop with cumulative exposure. The current TCCC guidelines have removed Hextend from the standard analgesic and resuscitation algorithm in favor of blood products.
Adult Dosing
Pediatric Dosing
Pediatric Hextend use is not addressed in primary TCCC doctrine. Pediatric hemorrhagic shock resuscitation uses crystalloid and blood products per civilian and pediatric advanced life support protocols.
Pharmacokinetics
Peak Effect: IV: peak volume effect during and immediately after infusion
Duration: Intravascular retention longer than crystalloid; sustained volume effect for 6 to 12 hours
Storage and Handling
Store at controlled room temperature (15 to 30 degrees Celsius). Avoid freezing. Inspect for clarity and particulates before administration.
Reconstitution:
Hextend is supplied as a ready-to-infuse 500 mL bag. No reconstitution required.
TCCC and TECC Role
Hextend was a TCCC standard for hemorrhagic shock resuscitation from approximately 2003 until the doctrine shift toward blood-based resuscitation. The 2026 TCCC guidelines do not recommend Hextend as primary therapy for hemorrhagic shock; blood products (whole blood preferred, then component therapy) are the standard when available. Hextend may still be encountered in legacy TCCC kits and may be carried for austere environments where blood products are not feasible. Providers should understand the FDA warnings and the shift in evidence base when considering Hextend administration.
Hextend is the colloid that earned its place in TCCC kits during the Iraq and Afghanistan era and has since lost that place. The 2013 FDA black box warnings and subsequent meta-analyses demonstrating increased mortality and renal injury in critically ill patients led the TCCC community to move toward blood products. Where Hextend retains a possible role is in extreme-austere environments without any blood products available, as bridging volume support for hemorrhagic shock, with full understanding that crystalloid (NSS or LR) is the better default in modern doctrine. Providers may still see Hextend in older kits; understand its history but rely on current evidence.
Using Hextend as a default colloid for shock resuscitation based on older training. Current TCCC and civilian critical care evidence shows worse outcomes with hetastarch in critically ill patients. Blood products are the modern standard for hemorrhagic shock; crystalloid is the default when blood is not available. The other common error is using Hextend in sepsis, where the FDA black box warning specifically applies.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
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Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Hextend
| IV/IO | Historical TCCC dose: 500 mL IV/IO over 5 to 10 minutes for hemorrhagic shock. May repeat once after 30 minutes if SBP remains under 90. Maximum 1000 mL (1500 mL absolute maximum in some sources). (Immediate (volume effect during infusion)) |