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DESCRIPTIONcolloid vs crystalloid debate
Colloid Solutions To Use or not to Use?
Ubaidur Rahaman Associate Consultant Critical Care Medicine
Fortis Flt. Lt. Rajan Dhall Hospital New Delhi 110070
the LV volume is a surrogate for LV wall tension
And the LV wall tension a surrogate for LV stroke volume
And the LV stroke volume determines CO
And the LV CO is a surrogate for tissue blood flow
And tissue blood flow is a surrogate for tissue oxygenation
And the tissue oxygenation is a surrogate for ATP generation
And ATP generation powers cellular function
10% Pentaspan 250/0.45
6% Hespan 450/0.60
6% Voluven 130/0.40
Classification of Strarch
Degree of substitution
Plasma- 25 mmHg
10% Pentaspan- 80 mmHg
6% Voluven- 26 mmHg
HES are polydispersible substances.
They contain a distribution of molecular weights.
The number on the package is the average
After infusion the molecules are broken down by
If their size is below the renal threshold, they are excreted.
Excretion of smaller particles continuously reduces osmotic effectiveness of infused solution.
Low MW solutions have more molecules per volume.
This gives them a greater oncotic effect.
Also gives them less persistence in plasma
This is where the drugs derive their name
0.6 = Hexastarch
0.5 = Pentastarch
0.4 = Tetrastarch
Proportion of the carbon atoms that are hydroxyethylated.
Expressed as a number from 0 to 1.
Most starches are substituted in the C2 or C6 position
Hydroxyethylation inhibits rate of destruction of starch polymer by amylase
Proportion of molecules that are hydroxyethylated
at the C2 vs C6 position.
A higher C2:C6 ratio results in longer intravascular half life.
Adverse effects of colloids
Seems to be more pronounced with the slowly degraded starches.
Predominant effect is on vWF:VIII.
Some platelet effects, but these are non significant
Multicenter randomized trial
Patients with severe sepsis
intensive insulin therapy or conventional insulin therapy
HES was harmful, and its toxicity increased with accumulating doses.
10% pentastarch HES 200/0.5 or modified Ringers lactate
for fluid resuscitation.
Methods Randomized controlled trial
7000 patients admitted to an intensive care unit Fluid resuscitation with
6% HES Voluven 130/0.4 or 0.9% sodium chloride
Conclusions No significant difference in 90-day mortality
between patients resuscitated with 6% HES (130/0.4) or saline.
More patients who received resuscitation with HES were treated with renal-replacement therapy.
The primary outcome was death within 90 days. Secondary outcomes included AKI and failure and treatment with
Limitation observed rate of death was lower than predicted.
Exclusion of patients with intracranial hemorrhage
and those whom clinicians considered unlikely to survive, Inclusion of patients who had undergone elective surgery.
Patients were recruited after admission to the ICU,
(when the requirements for fluid resuscitation are often less than those for patients in the emergency
department or the operating room)
Multicenter randomized trial Patients with severe sepsis
fluid resuscitation in the ICU 6% HES 130/0.42 (Tetraspan) or Ringers acetate
CONCLUSIONS Fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90
and were more likely to require renal-replacement therapy
The primary outcome measure was either death or end-stage kidney failure (dependence on dialysis) at 90 days after
In all these studies
There was no/ little difference in
Resuscitation volume of
Colloid and Crystalloid
( 1:1 to 1:1.5)
methods We randomly assigned patients admitted to the ICU
Fluid resuscitation with 4 percent albumin or normal saline .
conclusions In patients in the ICU, use of either 4 percent albumin or normal saline for fluid
resuscitation results in similar outcomes at 28 days
The primary outcome measure was death from any cause during the 28-day period after randomization.
Methods For patients with traumatic brain injury
baseline characteristics from case-report forms, clinical records, and CT scans were recorded
and vital status and functional neurologic outcomes were determined 24 months after randomization.
Post hoc follow-up study of patients with traumatic brain injury who were enrolled in SAFE study
Conclusions Fluid resuscitation
with albumin was associated with higher mortality rates than was resuscitation with saline.
Recommendations and conclusions We recommend not to use
HES with mw 200 kDa and/or degree of substitution 0.4 in patients with severe sepsis or risk of acute kidney injury
and suggest not to use 6% HES 130/0.4 or gelatin in these populations.
We recommend not to use colloids in patients with head injury
and not to administer gelatins and HES in organ donors.
We suggest not to use hyperoncotic solutions for fluid resuscitation.
We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are established
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and
septic shock (grade 1B).
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).
Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically
Ill Patients Presenting With Hypovolemic ShockThe CRISTAL Randomized Trial Djillali Annane, MD, for the CRISTAL Investigators
No significant difference in 28-day mortality.
Although 90-day mortality was lower among patients receiving colloids,
this finding should be considered exploratory and
requires further study before reaching conclusions about efficacy.
Colloids ( gelatins, dextrans, hydroxyethyl starches, or 4% or 20% of albumin) Vs
crystalloids (isotonic or hypertonic saline or Ringer lactate solution)
Involves caring for patients based upon explicit integration of pathophysiology, clinical experience
best available evidence, adapted to each individual and the local health care setting
Evidence Based Medicine
Evidence Based Medicine
Should not kill
The world is a dangerous place, not because of those who do evil, but because of those who look on and do nothing.
You are not only responsible for what you say, but also for what you do not say.
Martin Luther King