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Table of Contents
EDITORIAL
Year : 2015  |  Volume : 31  |  Issue : 3  |  Page : 293-294

Does the choice of colloids interfere with the outcome in critically ill patients? A critical appraisal


Department of Anesthesiology and Perioperative Medicine, University Hospital Brussels, Laarbeeklaan 101, 1090 Brussel, Belgium

Date of Web Publication29-Jul-2015

Correspondence Address:
Jan Poelaert
Laarbeeklaan 101, 1090 Brussel
Belgium
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.161652

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How to cite this article:
Poelaert J, Flamée P. Does the choice of colloids interfere with the outcome in critically ill patients? A critical appraisal. J Anaesthesiol Clin Pharmacol 2015;31:293-4

How to cite this URL:
Poelaert J, Flamée P. Does the choice of colloids interfere with the outcome in critically ill patients? A critical appraisal. J Anaesthesiol Clin Pharmacol [serial online] 2015 [cited 2021 Jul 26];31:293-4. Available from: https://www.joacp.org/text.asp?2015/31/3/293/161652

In this issue of the Journal, fluid management has been discussed in terms of a restricted or liberal approach. [1] Actually, two aspects have to be highlighted in this context:

  1. Acute caregivers will inherently restrict fluids in patients at risk for edema (cerebral or pulmonary edema, acute respiratory distress syndrome, cardiac decompensation).
  2. The discussion between liberal and restrictive management devolves to high volume resuscitation by crystalloids versus low volume optimization by colloids.


A restrictive policy appears logical when patients are at risk for developing edema or in whom restrictive fluid administration permits established homeostasis and stable hemodynamics without deterioration of renal function. The efficiency of low volume of colloids has been demonstrated in several settings, such as acute normovolemic hemodilution, [2] before and during spinal anesthesia (coloading or preloading, respectively) [3] and reversal of shock. [4] Therefore, a restrictive attitude is desirable, avoiding over-optimization of preload and blind correction of fluid responsiveness.

Nowadays, there is a debate on the use of hydroxy-ethyl starches (HES) in critically ill patients, especially in those with septic shock. Literature appears to blame HES containing colloids for most of the harmful effects. Several studies in the critical care setting demonstrated either no benefit or harm of HES. However the use of HES solutions and hyperoncotic solutions in septic shock and burn patients, [5] leads more frequently to acute kidney injury. [6],[7] This was true not only in the few patients in whom cumulative doses exceeded 250 ml/kg of HES, [5] but also when recommended doses were administered. Furthermore, coagulopathy has been described in some studies, [7],[8] but denied by others, [9] and is attributed to dilutional hypofibrinogenemia. [10],[11] It seems that main effects are closely related to the cumulative dose of the colloid.

These and other findings led to the publication of warnings and recommendations by European and American authorities, stating that HES is contraindicated in sepsis and burns, as well as in severe coagulopathy and liver dysfunction. [12] In perioperative care, HES solutions continue to be used in the setting of acute hypovolemia, in the absence of renal failure or significantly increased bleeding risk, though they are not really advantageous. [13] The corner stone in this debate is the correct use of HES with respect to a maximal dosing per 24 h (30 ml/kg/day HES 6%). In any case, a cautious and judicious use of these and other hyperoncotic solutions is warranted: Colloids are drugs, they have indications, maximum dose, and well-defined contraindications. Further studies have to elucidate their safety and harm in the perioperative setting.

 
  References Top

1.
Chatrath V, Khetarpal R, Ahuja J. Fluid management in patients with trauma: Restrictive versus liberal approach. J Anaesth Clin Pharmacol 2015;31:307-22.  Back to cited text no. 1
    
2.
Casati V, Speziali G, D′Alessandro C, Cianchi C, Antonietta Grasso M, Spagnolo S, et al. Intraoperative low-volume acute normovolemic hemodilution in adult open-heart surgery. Anesthesiology 2002;97:367-73.  Back to cited text no. 2
    
3.
Nishikawa K, Yokoyama N, Saito S, Goto F. Comparison of effects of rapid colloid loading before and after spinal anesthesia on maternal hemodynamics and neonatal outcomes in cesarean section. J Clin Monit Comput 2007;21:125-9.  Back to cited text no. 3
    
4.
Bayer O, Reinhart K, Kohl M, Kabisch B, Marshall J, Sakr Y, et al. Effects of fluid resuscitation with synthetic colloids or crystalloids alone on shock reversal, fluid balance, and patient outcomes in patients with severe sepsis: A prospective sequential analysis. Crit Care Med 2012;40:2543-51.  Back to cited text no. 4
    
5.
Schortgen F, Girou E, Deye N, Brochard L, CRYCO Study Group. The risk associated with hyperoncotic colloids in patients with shock. Intensive Care Med 2008;34:2157-68.  Back to cited text no. 5
    
6.
Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008;358:125-39.  Back to cited text no. 6
    
7.
Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012;367:1901-11.  Back to cited text no. 7
    
8.
Hartog CS, Bauer M, Reinhart K. The efficacy and safety of colloid resuscitation in the critically ill. Anesth Analg 2011;112:156-64.  Back to cited text no. 8
    
9.
Kasper SM, Meinert P, Kampe S, Görg C, Geisen C, Mehlhorn U, et al. Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at recommended doses. Anesthesiology 2003;99:42-7.  Back to cited text no. 9
    
10.
Fenger-Eriksen C, Anker-Møller E, Heslop J, Ingerslev J, Sørensen B. Thrombelastographic whole blood clot formation after ex vivo addition of plasma substitutes: Improvements of the induced coagulopathy with fibrinogen concentrate. Br J Anaesth 2005;94:324-9.  Back to cited text no. 10
    
11.
Fenger-Eriksen C, Tønnesen E, Ingerslev J, Sørensen B. Mechanisms of hydroxyethyl starch-induced dilutional coagulopathy. J Thromb Haemost 2009;7:1099-105.  Back to cited text no. 11
    
12.
EMA. Hydroxyethyl-starch solutions (HES) no longer to be used in patients with sepsis or burn injuries or in critically ill patients. http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals/Hydroxyethyl_starch-containing_solutions/human_referral_prac_000012.jsp&mid=WC0b01ac05805c516f.   Back to cited text no. 12
    
13.
Yates DR, Davies SJ, Milner HE, Wilson RJ. Crystalloid or colloid for goal-directed fluid therapy in colorectal surgery. Br J Anaesth 2014;112:281-9.  Back to cited text no. 13
    



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[Pubmed] | [DOI]



 

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