Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer...
Transcript of Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer...
![Page 1: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/1.jpg)
Colloids versus Crystalloids: Do we have an answer yet??
Lauralyn McIntyre MD, FRCP(C), MHScScientist, Ottawa Hospital Research Institute
Assistant Professor, University of OttawaDepartment of Epidemiology and Community Medicine
Center for Transfusion and Critical Care Research
![Page 2: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/2.jpg)
Conflicts of Interest
• Unrestricted funds CSL Behring
![Page 3: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/3.jpg)
The Colloid Crystalloid Question……
• Is one of the oldest• Basic yet fundamental question
• The first intervention given • To every patient • Often several litres • Since fluids critical for achievement of
hemodynamic stability, there is a potential for impact on clinically important outcomes
![Page 4: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/4.jpg)
Main categories of usual care resuscitation fluids
Crystalloid FluidNormal SalineRingers Lactate
Colloid FluidAlbuminHydroxyethyl starch
![Page 5: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/5.jpg)
Main categories of usual care resuscitation fluids
Crystalloid FluidNormal SalineRingers Lactate
Colloid FluidAlbuminHydroxyethyl starch
Other Colloids:GelatinsDextrans
![Page 6: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/6.jpg)
Components of Normal Saline and Ringers Lactate
28
0
Lactatemmol/L
272
308
Osmo-larity
2.7
0
Ca++mmol/L
4
0
K+mmol/L
109130Ringers Lactate
154154Normal Saline
Cl-mmol/L
Na+mmol/L
![Page 7: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/7.jpg)
• Most common human plasma protein (60%)• Synthesized in the liver• Molecular weight of 66 Kd• Responsible for 80% osmotic pressure
• Available:• Iso – oncotic (4 – 5%)• Hyper – oncotic (20 – 25%)
Quinlan et al, Hepatology, 2005
Albumin
![Page 8: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/8.jpg)
What are hydroxyethyl starch (HES) fluids?
• Amylopectin starch (branched chain glucose molecules)
Hydroxyethylation at C2 and C6 carbon units (substitution)
Vary in size (130 – 200 kD)Vary in the amount of substitution and ratio of substitution
![Page 9: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/9.jpg)
ISS10 L
IC30 L
Plasma3 L
Blood Cells2 L
Rationale for Resuscitating with Colloids compared to Crystalloids
![Page 10: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/10.jpg)
ISS10 L
IC30 L
Plasma3 L
Blood Cells2 L
Rationale for Resuscitating with Colloids compared to Crystalloids
Plasma3 L
Blood Cells2 L
Iso-oncotic colloid
![Page 11: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/11.jpg)
ISS10 L
IC30 L
Plasma3 L
Blood Cells2 L
Rationale for Resuscitating with Colloids compared to Crystalloids
Plasma3 L
Blood Cells2 L
Iso-oncotic colloidHyper-oncotic colloid
![Page 12: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/12.jpg)
ISS10 L
IC30 L
Plasma3 L
Blood Cells2 L
Rationale for Resuscitating with Colloids compared to Crystalloids
Plasma3 L
Blood Cells2 L
Iso-oncotic colloidHyper-oncotic colloid
ISS10 L
IC30 L
![Page 13: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/13.jpg)
ISS10 L
IC30 L
Plasma3 L
Blood Cells2 L
Rationale for Resuscitating with Colloids compared to Crystalloids
Plasma3 L
Blood Cells2 L
Iso-oncotic colloidHyper-oncotic colloid
ISS10 L
IC30 L
Optimization of the microcirculation?Impact on microcirculatory dysfunction?Modulation of inflammatory response
![Page 14: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/14.jpg)
The Colloid Crystalloid Question…
• Research on this question for several decades
• And yes, there have been many studies and many systematic reviews
![Page 15: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/15.jpg)
Cochrane Systematic Reviews
Author/Year Fluids compared # StudiesPerel, 2011 Colloids vs Crystalloids 56Bunn, 2011 Colloid vs Colloid 72Alderson 2009 Albumin vs no albumin 37Dart 2010 HES vs other fluid 34
![Page 16: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/16.jpg)
Cochrane Systematic Reviews
Author/Year Fluids compared # StudiesPerel, 2011 Colloids vs Crystalloids 56Bunn, 2011 Colloid vs Colloid 72Alderson 2009 Albumin vs no albumin 37Dart 2010 HES vs other fluid 34
So why are we still studying this question?
![Page 17: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/17.jpg)
Cochrane Systematic Reviews
Author/Year Fluids compared # StudiesPerel, 2011 Colloids vs Crystalloids 56Bunn, 2011 Colloid vs Colloid 72Alderson 2009 Albumin vs no albumin 37Dart 2010 HES vs other fluid 34
So why are we still studying this question?
• Small sample size• Single centre• Dated resuscitation protocols• Insufficient dose• Surrogate outcomes• Few studies in the critically ill• Low methodological rigor (risk of bias high)
![Page 18: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/18.jpg)
SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries
Finfer et al, Critical Care, 2010; 14:R185
![Page 19: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/19.jpg)
SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries
Finfer et al, Critical Care, 2010; 14:R185
![Page 20: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/20.jpg)
SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries
Finfer et al, Critical Care, 2010; 14:R185
![Page 21: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/21.jpg)
SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries
Finfer et al, Critical Care, 2010; 14:R185
![Page 22: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/22.jpg)
SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries
Finfer et al, Critical Care, 2010; 14:R185
![Page 23: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/23.jpg)
Are colloid fluids better maintained in the intravascular space as compared to
![Page 24: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/24.jpg)
RCT/Yr Population Fluid Comparators RatioCrystalloid/Colloid
SAFE/04 Critically illN = 6997
4% albumin vs normal saline
1.4
VISEP/08 Severe Sepsis/Septic Shock
N = 537
10% HES vs ringers lactate
1.4
McIntyre/08 Septic ShockN = 40
10% HES vsnormal saline
1.1
Hartog et al, Anesth and Anal 2011, 112:635-645
![Page 25: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/25.jpg)
RCT/Yr Population Fluid Comparators RatioCrystalloid/Colloid
SAFE/04 Critically illN = 6997
4% albumin vs normal saline
1.4
VISEP/08 Severe Sepsis/Septic Shock
N = 537
10% HES vs ringers lactate
1.4
McIntyre/08 Septic ShockN = 40
10% HES vsnormal saline
1.1
Hartog et al, Anesth and Anal 2011, 112:635-645
![Page 26: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/26.jpg)
RCT/Yr Population Fluid Comparators RatioCrystalloid/Colloid
SAFE/04 Critically illN = 6997
4% albumin vs normal saline
1.4
VISEP/08 Severe Sepsis/Septic Shock
N = 537
10% HES vs ringers lactate
1.4
McIntyre/08 Septic ShockN = 40
10% HES vsnormal saline
1.1
Hartog et al, Anesth and Anal 2011, 112:635-645
![Page 27: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/27.jpg)
RCT/Yr Population Fluid Comparators RatioCrystalloid/Colloid
SAFE/04 Critically illN = 6997
4% albumin vs normal saline
1.4
VISEP/08 Severe Sepsis/Septic Shock
N = 537
10% HES vs ringers lactate
1.4
McIntyre/08 Septic ShockN = 40
10% HES vsnormal saline
1.1
Hartog et al, Anesth and Anal 2011, 112:635-645
? Endothelial Cell Leak
![Page 28: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/28.jpg)
Are there potential harms associated with the use of colloid fluid in the
![Page 29: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/29.jpg)
Hydroxyethyl starches Albumin
Coagulopathy yes yes
Transmission viral infection no yes
Anaphylaxis yes(<0.006%)
yes(<0.1%)
Pruritis yes no
Renal Failure yes ?
Grocott, M, Anesthesia and Analgesia, 2005
![Page 30: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/30.jpg)
Hydroxyethyl starches Albumin
Coagulopathy yes yes
Transmission viral infection no yes
Anaphylaxis yes(<0.006%)
yes(<0.1%)
Pruritis yes no
Renal Failure yes ?
Grocott, M, Anesthesia and Analgesia, 2005
![Page 31: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/31.jpg)
Brunkhorst et al, NEJM, 2008
![Page 32: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/32.jpg)
Baseline CharacteristicsMean (SD)
Ringers LactateN=275
HESN=262
P value
Age 64.9 ±4.1 64.4 ± 13.3
Sex (male) (%) 59.6 60.3
APACHE II Score 20.3 ± 6.7 20.1 ± 6.7
Results (%) *RRT 18.8% 31% 0.001
Acute renal failure 22.8 34.9 0.001
28 day Mortality 24.1% 26.7% 0.484
90 day Mortality 33.9% 41% 0.092
Brunkhorst et al, NEJM, 2008*RRT = renal replacement therapy
![Page 33: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/33.jpg)
VISEP trial: HES dose and RRT
Brunkhorst et al, NEJM, 2008
![Page 34: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/34.jpg)
VISEP trial: HES dose and RRT
Brunkhorst et al, NEJM, 2008
Limitations of the VISEP Trial
• Fluid protocol violations • No criteria for dialysis
• Un-blinded study
![Page 35: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/35.jpg)
What evidence related to HES is forthcoming?
Trial Population Fluids compared Primary Outcome
6S Severe SepsisN = 800
Voluven vsRingers lactate
90 Day Mortality or Dialysis
CHEST Critically illN = 7000
Voluven vsNormal Saline
90 Day Mortality
![Page 36: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/36.jpg)
Finfer et al, NEJM 2004; 350: 2247 - 2256
![Page 37: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/37.jpg)
![Page 38: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/38.jpg)
![Page 39: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/39.jpg)
![Page 40: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/40.jpg)
![Page 41: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/41.jpg)
Survival 28 Days Survival 24 Months
Survival in SAFE TBI sub-group (n = 460)
20.4%
33.2%
![Page 42: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/42.jpg)
Survival 28 Days Survival 24 Months
Survival in SAFE TBI sub-group (n = 460)
20.4%
33.2%
Severe TBI (N = 290)
RR and 95% CI: 1.88 (1.31 to 1.70)
![Page 43: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/43.jpg)
SAFE TBI comments
• Post - hoc sub group analysis• Co-interventions for TBI not described• Biological mechanisms not clear
• Intracranial hypertension • 30% vs 34% albumin vs normal saline
![Page 44: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/44.jpg)
Predefined sub-group with severe sepsis n = 1218
Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
![Page 45: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/45.jpg)
SAFE Severe Sepsis: Baseline Characteristics
Albumin SalineAge 60.5 ±17.2 61.0±17.1
Gender (male) 59.6% 57.1%
APACHE II 21.6±7.8 21.8±7.7
Septic Shock 34.8% 37.3%ARDS 6.5% 6.8%Ventilation 56.8% 59.4%
![Page 46: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/46.jpg)
SAFE Severe Sepsis: 28 day mortality
Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
![Page 47: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/47.jpg)
SAFE Severe Sepsis: 28 day mortality
Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
![Page 48: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/48.jpg)
SAFE Severe Sepsis: 28 day mortality
Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
No differences in renal injury between fluid groups
![Page 49: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/49.jpg)
FEAST Trial
• 3141 African children with febrile illness and impaired perfusion
• Randomized to boluses of 5% albumin, normal saline, or no bolus
Maitland et al, NEJM, 2011
![Page 50: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/50.jpg)
FEAST Trial
• 3141 African children with febrile illness and impaired perfusion
• Randomized to boluses of 5% albumin, normal saline, or no bolus
Maitland et al, NEJM, 2011
Bolus5% albumin
Bolus normal saline
Control
48 hour death 10.6% 10.5% 7.3%
4 week death 12.2% 12.0% 8.7%
Neurologic sequlae
2.2% 1.9% 2.0%
Increased ICP or pulmonary edema
2.6% 2.2% 1.7%
![Page 51: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/51.jpg)
More evidence for albumin in sepsis is coming……
EARRS Trial ALBIOS Trial PRECISE Trial
Population
Septic shock within first 6 hours ICU
admission
Severe Sepsis/Septic Shock within 24 hours in
ICU
Early Septic shock from the ED
Sample Size
800 1800 1808
Intervention
Open label100 mls 20% albumin Q8H versus normal
saline for first 3 days in ICU
Open labelUp to 300 mls infused
20% albumin vs crystalloid fluid according to albumin levels in ICU
Double blindHead to Head 500 ml
boluses 5% albumin versus normal saline starting in ED
Primary Outcome
28 Day Mortality
28 Day Mortality 90 Day Mortality
![Page 52: Colloids versus Crystalloids: Do we have an answer … versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute](https://reader031.fdocuments.net/reader031/viewer/2022022513/5aefdcbf7f8b9a572b8eb33e/html5/thumbnails/52.jpg)
Colloids versus Crystalloids for Fluid Resuscitation: Do we have the ANSWERS yet?
Populations Albumin Hydroxyethyl starch
Heterogeneous critically ill Yes Evidence coming
Septic shock Evidence coming Evidence coming
Trauma SG evidence SG evidence
ARDS SG evidence SG evidence
Traumatic Brain Injury SG evidence SG evidence
Sub Arachnoid Hemorrhage ? ?
SG = evidence from sub group