colloids or crystalloid solutions? is this (still) the question?

Colloids or crystalloid solutions?Colloids or crystalloid solutions?

Is this (still) the question?Is this (still) the question?

Why

Who

What

When

Where

W

LIFE PRIORITIES

• PERFUSION

• O2

• pH

• electrolytes

Schiraldi

Adequate tissue oxygenation is known to be key factor in

determining tissue survival.

Resuscitation efforts in critically ill patients therefore target

restoration, normalisation and manteinance of regional blood

flow and oxygenation.

JL Vincent 2008

Adequate volume replacement appears to be

a cornerstone in management

as restoration of flow is a key component in

avoiding tissue ischemia or riperfusion injury.

Boldt

Dry and die, wet and survive

DODO2 = 2 = COCO** x CaO x CaO22#

COCO = stroke volume x FC

CaOCaO22 = (Hb x 1.34 x SaO2) + (PaO2 x 0.0031)

myocardial contractility

preload

afterload

Stroke Volume Heart Rate

COSVR

Blood Pressure

Rhythm

Hb SpO2

DO2

x

myocardial contractility

preload

afterload

Stroke Volume Heart Rate

COSVR

Blood Pressure

Rhythm

Hb SpO2

DO2

Currently, there is no consensus on

the clinical definition of hypovolemia. In

broad terms, patients who improve with

fluid therapy are hypovolemic.

Static indices of preload have no predictive power in hypovolemia.

Crit Care Med 2009 Vol. 37, No. 9

TBWTBW(Total Body Water)(Total Body Water)

60% of body weight60% of body weight

TBWTBW(Total Body Water)(Total Body Water)

60% of body weight60% of body weight

2/3 2/3 ICFICF2/3 2/3 ICFICF 1/3 1/3 ECFECF1/3 1/3 ECFECF

NaNa

H20

¾¾ INT INT1/4 1/4 PLPL

EABV

Tissues Perfusion

(700 ml)

• capacità di espansione volemicacapacità di espansione volemica

• persistenza in circolopersistenza in circolo

• effetti sulla cascata di attivazione della effetti sulla cascata di attivazione della SIRSSIRS

• influenza sul microcircoloinfluenza sul microcircolo

• sicurezzasicurezza

• reazioni avversereazioni avverse

LIC

FisiologicaFisiologica

Bilancio dopo la infusionedi 1 litro di soluzione:

Intravasale = 250

Interstiziale = 750

Intracellulare = 0

1 litro vasi

interstizio

LEC

Acqua libera(glucosata)

Acqua libera(glucosata)


Intravasale = 85

Interstiziale = 250

Intracellulare = 665

1 litro vasi

interstizio

LIC

LEC

ColloidiColloidi


Intravasale = 600 – 1000

Interstiziale = 0 – 400

Intracellulare = 0

1 litro vasi

interstizio

LIC

LEC

Ipertonica(NaCl 7,5 %)

Ipertonica(NaCl 7,5 %)


Intravasale = 7000

Interstiziale = disidratazione

Intracellulare = disidratazione

1 litro vasi

interstizio

LIC

LEC

INTRAVASCOLARE EXTRAVASCOLARE

Normale permeabilità capillare (PC)

CRISTALLOIDI 25% 75%

COLLOIDI 70% 30%

Aumentata PC

CRISTALLOIDI 15-20% 80-85%

COLLOIDI 60-70% 30-40%

Aumentata PC + disfunzione di membrana


COLLOIDI 50-60% 40-50%

INTRAVASCOLARE EXTRAVASCOLARE

Normale permeabilità capillare (PC)

CRISTALLOIDI 25% 75%

COLLOIDI 70% 30%

Aumentata PC


COLLOIDI 60-70% 30-40%

Aumentata PC + disfunzione di membrana


COLLOIDI 50-60% 40-50%

Distribuzione relativa di colloidi e cristalloidi Distribuzione relativa di colloidi e cristalloidi a 30-60 minuti dalla infusionea 30-60 minuti dalla infusione

Distribuzione relativa di colloidi e cristalloidi Distribuzione relativa di colloidi e cristalloidi a 30-60 minuti dalla infusionea 30-60 minuti dalla infusione

da Haljmae e Lindgren, 2000

Fluid Challenge TestFluid Challenge TestFluid Challenge TestFluid Challenge Test

Test di espansione volemica

…approximately 20 mL/kg of isotonic crystalloid,

followed by boluses of up to 1000 mL of

crystalloid or 500 mL of colloid given over 30

minutes to achieve adequate resuscitation.

Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign:

international guidelines for management of severe sepsis and septic

shock: 2008. Crit Care Med. 2008;36:296-327.

Increasing the infusion rate of an oliguric

patient from

100 ml/h to 200 or 300

provides no answer to the question of

etiology of oliguria nor does it

adequately treat volume depletion.

Chernow

As colloids are not associated with an

improvement in survival, and as they are more

expensive than crystalloids, it is hard to see how it is hard to see how

their continued use in these patients can be their continued use in these patients can be

justified outside the context of RCTsjustified outside the context of RCTs.

Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) Perel P, Roberts I

Cochrane Database of Systematic Reviews. 3, 2009.

No clinical differences were found between colloids and

crystalloids in most of the studies analyzed.

Given the significant difference in costs between both

groups of expanders and in light of the currently available

evidence, crystalloids should be used as first-choice

expanders.

Health Technology Assessment Database. 2010 Issue 4,

If a colloid has to be chosen, HES could be a cheaper substitute

than albumin in most cases; though its benefits have not been

proven over jellies, it is the cheapest choice.

The main adverse effects shown in HES were with older molecules

with high molecular weight and high degree of substitution and

not with the newer ones, such as Voluven, however given the

evidence available, the use of HES in patients with kidney function

impairment should be avoided.

Health Technology Assessment Database. 2010 Issue 4,

SAFE (Saline vs Albumin Fluid Evaluation) Study.

In nearly 7,000 critically ill patients, there was no

difference in outcome between the use of 4% human

albumin solution and normal saline.

N Engl J Med 2004; 350: 2247–56

Efficacy of Volume Substitution and Insulin

Therapy in Severe Sepsis (VISEP) trial

N Engl J Med. 2008;358:125-139

The VISEP trial was stopped early for safety

reasons. A planned interim analysis showed that

among 537 patients with severe sepsis

…patients receiving pentastarch were approximately 50% more

likely to have acute renal failure develop and were also more

likely to require renal replacement therapy.

N Engl J Med. 2008;358:125-139

The choice of intravenous fluid (colloid versus crystalloid)

does not appear to be a major determinant in outcome in

septic shock and the use of artificial plasma expanders

such as pentastarch should be avoided.

Engl J Med 2008; 358:125–139.

There are insufficient data to conclude that

synthetic colloids are safe in the critically ill

or to recommend their use when cheaper

crystalloid solutions are available.

HES solutions should be avoided in patients

with severe sepsis and septic shock

Merz,FinferControversies in Intensive Care Medicine 2008

ESCIM Europrean Society of Intensive Care Medicine

La fisiologica non è fisiologica

A balanced view of balanced solutions

Convincing evidence for clinically relevant adverse

effects of dilutional-hyperchloraemic acidosis on renal

function, coagulation, blood loss, the need for

transfusion, gastrointestinal function or mortality cannot

be found.

Crit Care. 2010 Oct 21;14(5):325

.

We believe that giving a sufficient quantity of

intravenous fluids rapidly and targeting

appropriate goals is more important than the

type of fluid chosen.

Schmidt 2009

• capacità di espansione volemicacapacità di espansione volemica

• persistenza in circolopersistenza in circolo

• effetti sulla cascata di attivazione della effetti sulla cascata di attivazione della SIRSSIRS

• influenza sul microcircoloinfluenza sul microcircolo

• sicurezzasicurezza

• reazioni avversereazioni avverse

high volume maintenance fluids

vs. low volume fluids

after the initial phase of the management

in septic shock

The NHLBI ARDS Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575

Whereas inadequate volume resuscitation is well recognized to

result in organ failure and death, excessive resuscitation places

the patient at risk for increased IAP, worsening visceral edema,

and cardiopulmonary dysfunction.

Cheatham M Crit Care Med 2008 36(3):1012-1014

World Society of the Abdominal Compartment Syndrome

… “reliance on overaggressive fluid therapy may worsen gut wall edema leading to further increases in IAP”.

“….in the bacteremic state, restoring APP and not just cardiac output may be important.”

New Blood, Old Blood, or No Blood?

Adamson JV NEJM 2008 358;12

Red blood cell transfusion in the critically ill:

When is it time to say enough?

Corwin, Shorr Crit Care Med 2009 37;6:2104

TRICC e TRAC

A multicenter, randomized, controlled clinical

trial of Transfusion Requirements in Critical Care

Hebert PC et al: N Engl J Med 1999; 340:409 – 417

TRICC

Transfusion Requirements After Cardiac Surgery

The TRACS Randomized Controlled Trial

Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.

JAMA. 2010;304(14):1559-1567

The data available would suggest that, in the

absence of acute bleeding, Hb of 7.0 –9.0 g/dL

are well tolerated by most critically ill patients

and that a transfusion threshold of 7.0 g/dL is

appropriate.

Corwin, Shorr Crit Care Med 2009 37;6:2104

Salvate il soldato Ryan

Does CVP predict fluid responsivness?

A sistematic review of literature and a tale of seven mares.

Mark et al CHEST 2008; 134:172-178

CVP should no longer be routinely measured in the

ICU, operating room, or ED.

CVP should not be used to make clinical decisions

regarding fluid management

In patients with cardiac depression from

anesthesia or sepsis, those with ongoing blood

loss, or those with systemic vasodilation,

it is certain that no useful relationship

between CVP and blood volume exists.

Leibowitz, ASA 2009

Based on the results of our systematic review, we

believe that CVP should no longer be routinely

measured in the ICU, operating room, or ED.

Mark et al CHEST 2008; 134:172-178

Using CVP to guide volume resuscitation fails

to acknowledge that this parameter is no

better than a coin toss in predicting who will

respond to fluids.

Durairaj L , Schmidt GA . Fluid therapy in resuscitated sepsis:less is more . Chest . 2008 ; 133 ( 1 ): 252 - 263 .

Osman D , Ridel C , Ray P , et al . Cardiac fi lling pressures arenot appropriate to predict hemodynamic response to volume

challenge . Crit Care Med . 2007 ; 35 ( 1 ): 64 - 68 .

colloids or crystalloid solutions? is this (still) the question?

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