Do We Still Need Colloids for Fluid Rescucitation?

Dr. Emre KarakoçÇukurova Üniversitesiİç Hastalıkları Yoğun Bakım Bilim Dalı

Resusitasyon Sıvıları Crystaloids vs Colloids

Albumin; preferred colloid Cost Might increase mortality in raumatic brain injury

HES More RRT High mortality ?

Balanced Crystaloid solutions 9% NaCl; metabolic asidosis and AKI Hypertonic salt solutions

Safety? N Engl J Med 2013;369:1243-51.

Grading System

1- Strong recommendation Highly recomended

2- weak recommendationWe recommend

Fluid Resuscitation Albumin in the resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystaloids (grade2C)

Fluid Resuscitation

Against the use of hydroxyethyl starches for the fluid resuscitation of severe sepsis and septic shock(Grade 1B)

SAFE Study

6045 patients 4% albumin vs %9NaCl

BMJ 2006;333:1044.

1218 patients 603 albumin 4% and 615 SF

SAFE Study - SEPSİS

Intensive Care Med (2011) 37:86–96

SAFE Study – SEPSIS – ORGAN faılure

Corrected Mortality Ratio: ALBUMIN vs. SF:

P= 0.03 odds ratio: 0.71; 95% CI: (0.52–0.97)

Intensive Care Med (2011) 37:86–96

Colloids Hydroxyethyl starch solutions (HES)

6%, molecular weight 130 kDMax. Daily dose 30 – 50 ml/kg/day

Gelatin Dextran solutions

VISEP Study 537 severe sepsis patients (275 Ringer

Lactate - 262 HES) HES…. 10% > 200kD

N Engl J Med 2008;358:125-39.

28 mortality mortalite: no differenceRL: 66/274 (24.1 %). HES: 70/262 (26.7 %)

90 day mortality: no differenceRL: 93/274 (33.9 %). HES: 107/261 (41.0

%) SOFA Scores

More AKI with HES (p < 0.001)More coagulation problems with HES

(p=0.02) Renal replasman teraphy

RL: 51/272 (18.8 %). HES: 81/261 (31.0 %)

VISEP Study

N Engl J Med 2008;358:125-39.

VISEP Study

Renal replasman teraphy and 90 day mortality are associated with cumulative HES doses (P<0.001 and P = 0.001sırası ile) fakat Ringer Laktat ile ilişkili değildir (P = 0.11 and P = 0.31, respectively).

N Engl J Med 2008;358:125-39.

Low Molecular Weight HES.CHEST Study

7000 ICU patients 3315 HES, 3336 SF

N Engl J Med 2012;367:1901-11.

More RRT with HESMore transfusionMore side effects

Low Molecular Weight HES.CHEST Study

N Engl J Med 2012;367:1901-11.

HES (130/0.42) vvs Ringer Acetate Severe Sepsis (6S Study) 800 patients HES maks. 33

ml/kg 400 HES - 400

RA No difference

28 mortality Number of

organ failure

Volume 0

10

20

30

40

50

60

90 günlük mortalite RRT gereksinimi

Per

cen

t (%

)HES

RA

Significant DifferencesP=0.03

P=0.04

N Engl J Med 2012;367:124-34.

Protocol violation28 patients in HES group and 41 patients in

RA group (More fluid then maximum daily doses)

No Criteria to start RRT Fluis volume; Acording to clinical evaluation..

HES (130/0.42) vvs Ringer Acetate Severe Sepsis (6S Study)

HES (130/0.4) vs. SFCRYSTMAS Study 186 sepsis patients 100 HES and 96 SF Hemodynamic targets

MAP ≥ 65 mmHg and at least 2 of the 3 criteria for 4 hours

1-CVP 8 – 12 mmHg 2-Urine output > 2 ml/kg 3-ScvO2 ≥ 70 %

Guidet et al. Critical Care 2012, 16:R94

Max. fluid: 50 ml/kg 1st day and 25 ml/kg until 4th day.

NS

HES (130/0.4) vs. SFCRYSTMAS Study

Guidet et al. Critical Care 2012, 16:R94

P=0.018

No difference in AKI No difference in 28 days mortality

HES %31 ve SF %25.3 (p>0.05)

HES (130/0.4) vs. SFCRYSTMAS Study

Guidet et al. Critical Care 2012, 16:R94

So …Which Fluid ?

As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.

The Cochrane Library 2013,

Last words are not spelled yet…

Keep calm and follow the guidelines…

Conclusion