Now information about the obligation matter of fluid management in critical ill patients. It was discussion about who will win Crystalloids or Colloids. From the received results is known, that the patient being in critical condition is better to be dry than wet. under all circumstances volume therapy should be guided by its effects on organ function and indicators of the adequacy of tissue oxygenation.
Volume
Perfusion
Microcirculation
Colloid Crystalloid
Crystalloids vs. Colloids Colloids vs. Colloids Crystalloid vs. Crystalloid Dry vs. Wet
Schierhout G:
Fluid resuscitation with colloid or crystalloid solution in critically ill patients: a systemic review. 1998 Crit Care Med 27: 200-210
Compared to Crystalloids 4% increased mortality when Colloids are the primary volume replacement
Choi P. et al.:
(Isotonic) Crystalloid vs. Colloids in fluid resuscitation: a systematic review. 1999 Critical Care Medicine, 27: 200-210
Mortality unchanged In the group of trauma patients significant better results when using crystalloids Number of pulmonary edema without difference No difference in ICU stay
Bunn F. et al.:
Colloid solutions for fluid resuscitation. Cochrane Database Syst Review 2003(1): CD001319
There is no evidence that one colloid solution is more effective or safe than any other.
Hands up !!
1. Colloids are more effective than crystalloids 2. HES is more effective than other colloids 3. HES influence outcome more positive compared to crystalloids, albumin, dextran or gelatin
Boldt J, Schllhorn T, Dieterich HJ: Volumentherapie in Deutschland eine Ist-Analyse anhand einer Fragebogenaktion. Ansth Intensivmed 47: 309-317 (2006)
Albumin
Increased mortality after albumin administration in critically ill patients
Cochrane Injuries Group Albumin reviewers 1998 BMJ
No differences in outcome (new organ failure, duration of ventilation, renal replacement therapy, length of stay) and mortality after albumin administration (vs. saline)
Wilkes MM: Patient survival after human albumin administration. A meta analysis of randomized, controlled trials. Ann Intern Med 2001: 149-164. The SAFE (Saline vs. Albumin Fluid Evaluation) Study Investigation. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-56
Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study
% albumin administration
Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study
Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study
Cumulative survival
Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study In this observational study of 3,147 patients, albumin administration was independently associated with a lower 30-day survival
Moreover, in 339 pairs matched according to a propensity score, ICU and hospital mortality rates were higher in patients who received albumin than in those who did not While albumin administration may be safe in patients requiring fluid for intravascular volume depletion, these results suggest it may not be harmless in all ICU patients.
Vincent JL et al. Critical Care, 9:R745-R754 (2005)
RESUSCITATION FROM SEPTIC SHOCK WITH CAPILLARY LEAKAGE: HYDROXYETHYL STARCH (130 KD), BUT NOT RINGERS SOLUTION MAINTAINS PLASMA VOLUME AND SYSTEMIC OXYGENATION
Key conclusion:
HES 130 kD could maintain PV and COP, thereby preserving systemic oxygenation and hemodynamics.
These results suggest the intravascular persistence of the artificial colloid in the presence of albumin leakage.
30 children less than 3 years undergoing cardiac surgery. Volume replacement with 6 % HES (200/0.5) vs. 20% human albumin (pre-bypass period). Outcome measures: HR, MAP, CVP, BGA, colloid osmotic pressure, electrolytes, fibrinogen, AT III, albumin, platelet count, overall coagulation tests, urine output, creatinine, blood loss, total use of homologous blood, FFP and platelet concentrates.
No significant Difference (except Albumine concentration) Conclusion: LMW-HES ist safe and effective in pediatric cardiac surgery
Fluid resuscitation in severe sepsis and septic shock: Albumin, hydroxyethylstarch, gelatin or ringers solution lactate: Does it really make a difference?
Surgical Operation
4h RL resuscitation
Key conclusion: although albumin and HES solution were associated with higher cardiac output and DO2, and lower blood lactate levels than gelatin and RL, our results suggest that the type of i.v. fluid used for initial fluid resuscitation has limited effects on outcome.
Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)
Next Round
Fluid Resuscitation during capillary leakage: Does the type of fluid make a difference?
Cohort, multi-center, observational study 198 ICU 24 European countries total of 3,147 patients
Determinants of insensible fluid loss. Perspiration, protein shift and endothelial glycocalyx
Fluid Input Fluid Output
Colloid (ml)
Determinants of insensible fluid loss. Perspiration, protein shift and endothelial glycocalyx
Blood Loss
Albumin should be used with caution in critical ill patients, although in pt. with low albumin it may be beneficial dry seems to be more beneficial than wet Colloids (HES, Gelatin) have some advantages regarding fluid therapy in sepsis
but
there is concern about the increased risk of acute renal failure with HES administration
and
under all circumstances volume therapy should be guided by its effects on organ function and indicators of the adequacy of tissue oxygenation. and
Reinhart K, Nephrol Dial Transplant 11, editorial comment (1996)
Thank you