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Clash of the titans: Colloids versus crystalloids

Clash of the titans: Colloids versus crystalloids. Eric A J Hoste Intensive Care Unit Ghent University Hospital Belgium. Are we asking the correct question?. The FEAST study Febrile illness, Africa N = 3141 + 29. Maitland et al. N Engl J Med 2011. Relevant question.

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Clash of the titans: Colloids versus crystalloids

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  1. Clash of the titans: Colloids versus crystalloids Eric A J Hoste Intensive Care Unit Ghent University Hospital Belgium

  2. Are we asking the correct question? The FEAST study Febrile illness, Africa N = 3141 + 29 Maitland et al. N Engl J Med 2011

  3. Relevant question Finfer et al SAFE TRIPS, Crit Care 2010

  4. Why would you choose colloids? Fast shock reversal = survival • EGDT! Less volume < IAH/ACS

  5. Why would you choose colloids? Fast shock reversal = survival • EGDT! Less volume • < IAH/ACS • < ARDS

  6. Why would you not choose colloids? Cost Side effects • Acute Kidney Injury • Coagulation abnormalities • … Worse Survival

  7. Price (€)

  8. No Colloids

  9. “The review of trials found no evidence that colloids reduce the risk of dying compared with crystalloids”

  10. Cochrane systematic review

  11. Cochrane systematic review

  12. Limitations of the meta-analysis Heterogeneity • Cohorts: non-ICU, burns, sepsis, trauma, … • Products: • Alb 4, 5, 20, 25% • HES 6, 10%, 1st, 2nd, 3rd generation • Saline, Ringer’s • … Small studies

  13. The SAFE study : Albumin 4% N = 6,997 patients The SAFE study investigators N Engl J Med 2004

  14. Subgroups? The SAFE study investigators N Engl J Med 2004

  15. Traumatic Brain Injury No to albumin N = 460 patients GCS 3-8 Myburgh et al. N Engl J Med 2007

  16. Severe sepsis? N = 919/1218 Yes to albumin Finfer et al. Intensive Care Med 2011

  17. EARSS: Albumin 20% in septic shock Results • Albumin concentration • All individual organ dysfunctions equal • Same outcome at 28-d N = 794 patients No Benefit Abstract ESICM Berlin 2011

  18. HES 200, 10% vs. Ringer’s N = 537 patients Brunkhorst et al, VISEP study. N Engl J Med 2008

  19. HES 200, 10% vs. Ringer’s N = 537 patients Brunkhorst et al, VISEP study. N Engl J Med 2008

  20. HES 130, 6% PRCT, N = 130 P = NS P = NS mortality Guidet et al. CRYSTMAS, abstract ESICM 2011

  21. Summary survival

  22. No Colloids

  23. Acute Kidney Injury N = 52, PRCT Brain dead kidney donors N = 129, PRCT Severe sepsis/septic shock AKI = creat x 2 or RRT Schortgen et al. Lancet 2004 Cittanova et al. Lancet 1996

  24. HES 200, 10% N = 537 P = 0.002 P = 0.001 Brunkhorst et al, VISEP study. N Engl J Med 2008

  25. CRYSTMAS: HES 130, 6% vs. saline Guidet, Abstract ESICM Berlin 2011

  26. Albumin and AKI SAFE study: No difference in duration of RRT EARSS study: No difference in organ dysfunction Spontaneous Bacterial Peritonitis: Albumin = less AKI Sort et al. N Engl J Med 1999 Hepatorenal syndrome: Albumin improves HRS Ortega et al. Hepatology 2002

  27. Summary: AKI

  28. No Colloids

  29. Coagulation tests? Multivariate analysis: aPTTassociated with: • Albumin (p=0.01) • Large volume (p=0.03) N = 687 3 units of the SAFE study group Bellomo et al. Crit Care Resusc 2009

  30. So, • Survival is better or worse or equal • AKI is equal or more (> older HES) • Coagulation abn: yes But: What about volume & early shock reversal?

  31. Less volume

  32. N = 237 656 mL fluid/d less Less wound infections Less pacing More need for plasma (p=0.048) EARSS, abstract ESICM 2011 Magder et al. Crit Care Med 2010

  33. Take home messages • Cost Crystalloid: 5 to 25 times lower • Survival: 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

  34. Ongoing ICU studies

  35. Thank You Eric.Hoste@Ugent.be

  36. Relevant question Finfer et al SAFE TRIPS, Crit Care 2010

  37. Acid-Base? N = 691 3 units Multivariate analysis: >3 L fluid resuscitation Cl: alb>saline Bellomo et al. Crit Care Med 2006

  38. Better when albumin is low? Finfer et al. BMJ 2006

  39. Acute Kidney Injury Zarychanski et al. Open Med 2009

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