Colloids versus crystalloids for fluid resuscitation in critically ill patients
ABSTRACT Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.
To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.
We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S), and The Controlled Trials metaRegister (www.controlled-trials.com). Reference lists of relevant studies and review articles were searched for further trials. The searches were last updated in September 2008.
Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates.
Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.
We identified 65 eligible trials; 56 of these presented mortality data.Colloids compared to crystalloidsAlbumin or plasma protein fraction - 23 trials reported data on mortality, including a total of 7754 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (95% CI) 0.92 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.91 to 1.09). Hydroxyethyl starch - 17 trials compared hydroxyethyl starch with crystalloids, n = 1172 patients. The pooled RR was 1.18 (95% CI 0.96 to 1.44). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05).
There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
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ABSTRACT: In patients who cannot, must not or do not want to drink, hydration is a real artificial nutrition intervention. Different clinical situations require a specific approach for fluid administration to reduce the risk of tissue hypoperfusion or oedema. The variations of plasma volume depend not only on the amount of the fluid infused, but also on its distribution, which is determined by the membranes’ properties. Fluids for intravenous therapy are not vehicles but real drugs and the knowledge of their properties should guide the choice: the available data on mortality and major complications do not demonstrate the best efficacy between crystalloids or colloids and between the different types of colloids: saline solution at 0.9% is commonly defined as “physiological”, but has significant differences with plasma; balanced electrolytic solutions seem to give better clinical outcomes compared to saline, which is ultimately overprescribed. 5% glucose solution is equivalent to water because glucose is rapidly metabolised, releasing it. It is necessary to strengthen educational interventions to improve the management of fluid therapy.Mediterranean Journal of Nutrition and Metabolism 12/2009; 2(3):163-169. DOI:10.1007/s12349-009-0066-z
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ABSTRACT: Introduction Apoptosis, or programmed cell death, seems to play a role in the physiology of shock. The influence of fluid resuscitation on the occurrence of apoptosis during haemorrhage is still unclear. Using an experimental randomised study, the goal of this investigation was to find a relation between different frequently used resuscitation fluids and evidence of apoptosis. Materials and methods Sixty female pigs with a mean body weight of 20 kg were randomised into six groups, each receiving a different resuscitation fluid therapy: malated Ringer, lactated Ringer, hypertonic saline, hypertonic saline solution/Dextran 60, carbonate/gelatine and a sham group (no shock, no resuscitation). A haemorrhagic shock with a predefined oxygen debt with high mortality expected was induced for a period of 60 min. Then, the resuscitation fluid therapy within each group was initiated. At the beginning, after 1 h of shock and 1 and 2 h after resuscitation, biopsies from the liver were taken, as one of the most important metabolism organs of shock. Three hours after the beginning of the resuscitation period, the animals were allowed to recover under observation for 3 days. At the end of this period, a state of narcosis was induced and another liver biopsy was taken. Finally, the animals were sacrificed and samples were taken from the liver, kidney, heart and hippocampus. The TUNEL method was used for identifying apoptosis. Impairment of liver function was indicated by the measurement of transaminase levels. Results There was no observed difference in the rate of apoptosis in all groups and a low number of apoptotic cells were found in all the organs sampled. The sham group also showed a low count of apoptosis. The hypoxia-sensitive neurons within the hippocampus did not show any signs of apoptosis. The high oxygen debt during haemorrhage led to a high mortality. The non-treated animals died very quickly, as an indicator for severe shock. Animals treated with hypertonic saline showed a significant increase in aspartate transaminase (AST) plasma levels on the first day after shock. Conclusion The different resuscitation fluids used in the treatment of haemorrhagic shock in this experimental model showed no evidence of a different apoptosis rate in the end organs.European Journal of Trauma and Emergency Surgery 08/2013; 39(4). DOI:10.1007/s00068-013-0279-1 · 0.38 Impact Factor
- AACN Advanced Critical Care 24(4):360-1. DOI:10.1097/NCI.0b013e3182a6ee6d