Colloid versus Crystalloid Controversy

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Colloid versus Crystalloidin Hypovolemic
ShockControversy
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• Crystalloids
• Fluids comprised of water and electrolytes or
  simple crystals
• Volume of distribution-intravascular,interstitial
  space
• Volume - 3 1
• Examples
• Ringers lactate, hypertonic saline, normal saline

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Colloid

• High molecular weight substances
• Volume of distribution -intravascular space
• Volume 1 1
• Exert colloid osmotic pressure
• Costly
• Examples
• HES, Haemaccel, Albumin, Dextran

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Crystalloids Colloids
Intravascular vol effect - Better
Interstitial vol. effect Better -
Pulmonary edema Similar potential Similar potential
Peripheral edema Common Uncommon
Reactions Absent Common
Cost Inexpensive Expensive
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Albumin

• 5, 20 and 25
• Half life 16 hr
• Colloidal osmotic pressure - (25) - 70 mmHg
• ? plasma volume by 400-500 ml
• Vol. expansion occur at expense of interstitial
  fluid so 25 should not be used for resuscitation
• Side effects allergic reaction

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Haemaccel

• Synthetic colloid
• Degraded gelatin
• Concentration - 3.5
• Half life 2-3 hr
• Dose 20 ml/kg/day
• Osmotic pressure 300 mmHg
• Side effects anaphylaxis, coagulation
  interference (high dose)

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Hydroxyethyl starch
M.wt (KD) Conc. I.V.stay (hrs) Dose (ml/kg/day)
200 3 1-2 60
200 6 3-4 30
200 10 4-8 20
450 6 6-8 20
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Crystalloids vs Colloids

• Proponents of colloid fluid
• Resuscitation crystalloid solution dilutes plasma
  proteins
• Reduction of plasma oncotic pressure
• Interstitial pulmonary edema
• Requires smaller initial volume, generate
  prolonged ? in circulating plasma volume
• Isotonic crystalloid must be infused at least
  three fold greater volumes- to achieve comparable
  plasma expansion and hemodynamic stability

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• Proponents of crystalloid solution
• Additional cost and potential risk of colloids
• Removal of colloids- requires longer period than
  crystalloids in burn and major surgical patients
• Sepsis, ARDS, surgical trauma, ? capillary
  permeability ? leak ? edema
• Coagulopathy Dextran, HES gt20 ml/kg
• ? ionised calcium albumin
• Impaired cross-matching Dextran
• Osmotic diuresis ? LMW dextran

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literature
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Crystalloid vs. Colloids in fluid resuscitation A systematic review Peter Choi et al (1999) RCT 814 pts. No apparent difference in pulmonary edema, mortality or length of stay between isotonic crystalloid and colloid resuscitation Crystalloid resuscitation- lower mortality in trauma patients
Fluid resuscitation with colloid or crystalloid - critically ill patients Schierhout G et al, 1998 Metanalysis 26 RCTs 1622 pts. Increased risk for death of 4 with colloid for resuscitation
Cochrane review 30 RCTs 1419 pts. Risk for death higher in albumin treated gp. Vs. albumin crystalloid gp.
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BMJ 1998317(7153)235-240 RCT Multicenter 42 pts. No statistically significant difference b/w crystalloid and albumin gps. w.r.t. days on mechanical ventilation, oxygenation failure, length of ICU stay and mortality rate in critically ill pts. with shock
SAFE trial N Engl J Med 2004350(22)2247-2256 RCT 6997 pts. No difference b/w albumin and saline w.r.t mortality rate, days of stay in ICU/ hospital/ ventilation

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What to do ?

• According to literature
• Crystalloids - first preference-when
  available(NS,R/L)
• Colloids Keeping in view of adverse effects and
  dosage ,colloids can be given with crystalloids
• Avoid albumin as resuscitative fluid

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