The debate,Crystalloids or

Colloids .
Iqbal Mustafa
ICU NCCH Harapan Kita
Jakarta

Summary
The debate is still going on.
Fkuid therapy should be based on the specific
needs of patient.
Crystalloids are neede for correction extravascular
fluid,but large volume carry risk for tissue edema ,
and organ dysfunction.
Colloids are preferred when the main indication is
to increase intravascular volume.

The Debate
Colloid vs Crystalloid
Colloid vs Colloid
Pro Con Albumin
Crystalloid vs Crystalloid

Albumin
Albumin may leak into the interstitial space:
over-albuminization

Question the clinical utility of maintaining the

COP, pulmonary dysfunction may be
unrelated to COP

Banish albumin from the ICU

Boldt, Intensive Care
Med 1998;24:28-36

 NS vs albumin 5 % in septic pts.

Albumin increased ECFV by double the
amount of infused. PV expanded by
equal amounts of volume

D02 did not increase.

Ernest et al Crit Care

Med 1999; 27:46-50.

Meta analysis pro albumin

Records of serious adverse events from 10091997: 100 million doses of human albumin
Adverse events: 123
No death attributable to albumin
Fatal adverse events possibly related to
albumin: 5,2 per 100.million dose
Von Hoegen Crit Care Med 2001;29:994-996.

Wilkes Navickis
Meta-analysis of 55 trials (n= 3504) for

mortality data. Albumin vs crystalloid

6 categories : surgery, trauma, burns,
hypoalbuminemia, neonates, ascites,
other indications (ARDS, shock)
RR was 1.11 (CI 0,95 -1,28)
No evidence albumin affected mortality

Ann Intern Med

2001;135:149-164.

Colloids vs Crystalloid
Critics to Schierhout, Cochrane, and Choi:
Large number of the studies (>50%)
conducted prior to 1990

Few trails were blinded, heterogeneous

None of the meta analyses supported the
conclusion that choice of resuscitation fluid
was critical for patient mortality
Webb Crit Care 2000;4:S26-S32.

 Hemorrhagic shock: combinations of colloids

and crystalloids, HS and/or HSD and
isotonic crystalloids especially for interstitial
compartment
Use of fluid resuscitation: aggressive fluid
resuscitation with any solution may be
harmful in penetrating thoraco-abdominal
(transport time less than 30 minutes)
Inflammatory response, ischemia
reperfusion, sepsis delayed restoration of
micro vascular flow would be dangerous
colloid.

Cochrane Review

24 RCT (1204 pts)

Hypovolemia, burns, or hypoalbuminemia
Albumin vs crystalloid
Every 17 critically ill patients treated with albumin
there is 1 additional death

Albumin should not be used outside the context of

RCT.

BMJ 1998;317:235-240.

Colloid vs Crystalloid
19 RCT (n=1315)
RR: 1,19; 4% increased risk of death for pts
receiving colloid (stat not significant)

Too many heterogeneous studies has been

included

Only 5 of the 19 trials involved commonly

used colloid, and among those mortality was
reduced in colloid group
Schierhout, Roberts

BMJ

Crystalloid vs Colloid
17 studies (814 pts)
No clear differences exits between colloids and
crystalloids with respect to all cause mortality

Subgroups analysis : in trauma pts crystalloid

are better

Critics: Differences in COP between treatment

groups can not be assessed

Young trauma pts, and elective surgical pts

Choi et al Crit Care Med 1999;27:2002-10.

Hypertonic vs Isotonic Crystalloid

16 trials: 837 pts

Conclusion: no definitive
conclusions could be reached for
resuscitation in burns, trauma or
surgical pts.

Bunn et al Cochrane 2000.

Colloid vs Crystalloid
29 pts abdominal surgery : 5% albumin or RL
COP in the albumin group did not change, fell
40 % in the RL

Fluid balance, COP-PCWP did not correlate

with Qs/Qt (increased in both group)

Questioned the necessity of maintaining COP

by colloids
Virgilio et al Surgery
1979;85:129-139.

Colloid vs Crystalloid
Meta-analysis with mortality as an
endpoint

8 RCT, mortality in favor of crystalloids,

especially in trauma pts

In non trauma pts the mortality rate

shifted in favor of colloid
Velanovich Surgery 1989;105:65-71.

Colloid vs Crystalloid
3 group: surgical stress, hypovolemia, severe
pulmonary failure

No differences in mortality rates

Argued for crystalloid due to the cost
difference
Bisonni et al J Fam P..Pract 1991;32:387-390.

Colloid vs Colloid( 2001)

Cochrane Review: 52 trials(1029 pts)
Outcome: death, amount of blood, adverse
reactions

Albumin vs HES
HES vs Gelatin
Albumin vs Gelatin
Conclusion: insufficient evidence to determine
which is more effective.

Comparative Review of
Dextran, Gelatin, HES
Effect on coagulation
Dextran and High MW-HES strongly associated with
impaired coagulation and higher pot op blood loss

Gelatin and low Mw HES do not appear to impair

hemostasis

All synthetic colloids might potentially induce

increased bleeding after infusion of large volumes.

de Jonge e et al Crit Care Med

2001;29:1261-1267.

 Colloids are superior to crystalloids at

attaining resuscitation endpoint

Advantages of albumin over synthetic colloid:

less restrictive dose, reduced risk of
coagulopathy, elimination of the risk of
pruritus of HES, and reduced risk of
anaphylaxis
Groeneveld Crit Care 2000;4:S16-S20.

Albumin vs HES

150 critically ill

150 post op with sepsis
No diff. in coagulation Parameters
Albumin more costly
Boldt et al Anesth Analg 1996;83:254-261.

Functional capillary density (upper graph) and tissue PO2 (lower graph)
after hemodilution (hemodil) and exchange with Ringers lactate or
Dextran.* p<0.05 versus baseline

The relative distribution of crystalloid and colloid solutions in the intra- and
extravascular fluid space at equilibrium (within 30 min to 1 hour of infusion)
Fluid

Intravascular

Extravascular

Normal capillary permeability

Crystalloid
Colloid

20%
70%

80%
30%

Increased capillary permeability

Crystalloid
Colloid

15-20%
60-70%

80-85%
30-45%

Increased capillary permeability + cell

membrane dysfunction
Crystalloid
Colloid

10-15%
50-60%

85-90%
40-50%