Clash of the titans: Colloids versus crystalloids Eric A J Hoste Intensive Care Unit Ghent...
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Transcript of Clash of the titans: Colloids versus crystalloids Eric A J Hoste Intensive Care Unit Ghent...
Clash of the titans: Colloids versus crystalloids
Eric A J HosteIntensive Care Unit
Ghent University HospitalBelgium
•Are we asking the correct question?
Maitland et al. N Engl J Med 2011
The FEAST studyFebrile illness, AfricaN = 3141 + 29
•Relevant question
Finfer et al SAFE TRIPS, Crit Care 2010
•Why would you choose colloids?
Fast shock reversal = survival EGDT!
Less volume< IAH/ACS
•Why would you choose colloids?
Fast shock reversal = survivalEGDT!
Less volume< IAH/ACS< ARDS
•Why would you not choose colloids?
Cost
Side effectsAcute Kidney InjuryCoagulation abnormalities …
Worse Survival
•Price (€)
•No Colloids
Survival
Acute Kidney Injury
Coagulation abnormalities
“The review of trials found no evidence that colloids reduce the risk of dying compared with crystalloids”
•Cochrane systematic review
N studies N patients RR
Albumin 23 7,754 1.01 (0.92-1.10)
HES 17 1,172 1.18 (0.96-1.44)
Gelatin 11 506 0.91 (0.49-1.72)
Dextran 9 834 1.24 (0.94-1.65)
Colloids in hypertonic 8 1238 0.88 (0.74-1.05)
•Cochrane systematic review
N studies N patients RR
Albumin 23 7,754 1.01 (0.92-1.10)
HES 17 1,172 1.18 (0.96-1.44)
Gelatin 11 506 0.91 (0.49-1.72)
Dextran 9 834 1.24 (0.94-1.65)
Colloids in hypertonic 8 1238 0.88 (0.74-1.05)
•Limitations of the meta-analysis
HeterogeneityCohorts: non-ICU, burns, sepsis, trauma, …Products: – Alb 4, 5, 20, 25% – HES 6, 10%, 1st, 2nd, 3rd generation– Saline, Ringer’s– …
Small studies
•The SAFE study : Albumin 4%
The SAFE study investigators N Engl J Med 2004
N = 6,997 patients
•Subgroups?
The SAFE study investigators N Engl J Med 2004
•Traumatic Brain Injury
Myburgh et al. N Engl J Med 2007
GCS 3-8N = 460 patients
No to albumin
•Severe sepsis?
Finfer et al. Intensive Care Med 2011
N = 919/1218 Yes to albumin
•EARSS: Albumin 20% in septic shock
ResultsAlbumin concentrationAll individual organ dysfunctions equalSame outcome at 28-d
No Benefit
Abstract ESICM Berlin 2011
N = 794 patients
•HES 200, 10% vs. Ringer’s
Brunkhorst et al, VISEP study. N Engl J Med 2008
N = 537 patients
•HES 200, 10% vs. Ringer’s
Brunkhorst et al, VISEP study. N Engl J Med 2008
N = 537 patients
•HES 130, 6%
Guidet et al. CRYSTMAS, abstract ESICM 2011
P = NS P = NS
PRCT, N = 130
mor
talit
y
•Summary survival
Study Colloid Survival
SAFE Albumin 4% Sepsis
EARSS Albumin 20%
VISEP HES 200, 10% >dose
CRYSTMAS HES 130, 6%
•No Colloids
Survival
Acute Kidney Injury
Coagulation abnormalities
•Acute Kidney Injury
N = 129, PRCTSevere sepsis/septic shockAKI = creat x 2 or RRT
Cittanova et al. Lancet 1996 Schortgen et al. Lancet 2004
N = 52, PRCTBrain dead kidney donors
•HES 200, 10%
P = 0.002 P = 0.001N = 537
Brunkhorst et al, VISEP study. N Engl J Med 2008
•CRYSTMAS: HES 130, 6% vs. salineHES Saline P
N 65 65Volume (mL) 1380 1708 NS
Time to HD stab (h) 11.8 14.3 NS
AKI-RIFLE 0.808
RRT 22.2% 14.7% 0.180Bleeding NS
INR NS
Itching 3 3 NS
Death 28-d 31% 25.3% NS
Death d-90 40% 33% NS
Guidet, Abstract ESICM Berlin 2011
•Albumin and AKI
SAFE study: No difference in duration of RRT
EARSS study: No difference in organ dysfunction
Spontaneous Bacterial Peritonitis: Albumin = less AKISort et al. N Engl J Med 1999
Hepatorenal syndrome: Albumin improves HRS Ortega et al. Hepatology 2002
•Summary: AKI
Study Colloid AKI
Cittanova - Kidney Donor HES 200 Yes
Schortgen - Severe sepsis HES 200 Yes
VISEP - Severe sepsis HES 130 No diff
SAFE –ICU Alb 4% No diff
EARSS – sepsis Alb 20% No diff
Cirrhosis - HRS Alb 20% Improved
Cirrhosis - SBP Alb 20% Improved
•No Colloids
Survival
Acute Kidney Injury
Coagulation abnormalities
•Coagulation tests?
Albumin SalineaPTT + 2.7 sec -0.9 secINR No
changeNo
change
Platelets
Multivariate analysis: aPTT associated with:Albumin (p=0.01) Large volume (p=0.03)
Bellomo et al. Crit Care Resusc 2009
N = 6873 units of the SAFE study group
•So,
Survival is better or worse or equalAKI is equal or more (> older HES)Coagulation abn: yes
But: What about volume & early shock reversal?
•Less volume
Catecholamines0%5%
10%15%20%25%30%35% HES Saline
Magder et al. Crit Care Med 2010
656 mL fluid/d lessLess wound infectionsLess pacing
N = 237 More need for plasma (p=0.048)
EARSS, abstract ESICM 2011
•Take home messages
Cost Crystalloid: 5 to 25 times lowerSurvival: equal– Alb 4%: survival in severe sepsis– HES 200: Survival when high volume HES 200
Side effects: – AKI: HES 200– Coagulation ≈ volume!
Don’t throw the baby out with the bad water
•Ongoing ICU studies
patients n Cryst Colloids Outcome
Annanne ICU 3010 >saline >HES 28-d mort
CHEST ICU 7000 Saline HES 130 90-d mort
ALBIOS Severe sepsis 1350 Any Alb>30 28-d mort
6S Severe sepsis 800 Ringer’s acetate
HES 130 acetate
90-d mort/ESKD
•Thank You
•Relevant question
Finfer et al SAFE TRIPS, Crit Care 2010
•Acid-Base?
N = 6913 units
Bellomo et al. Crit Care Med 2006
Multivariate analysis:>3 L fluid resuscitationCl : alb>saline
•Better when albumin is low?
Finfer et al. BMJ 2006
•Acute Kidney Injury
Zarychanski et al. Open Med 2009