1. Colloid Solutions
To Use or not to Use?
Ubaidur Rahaman
Associate Consultant Critical Care Medicine
Fortis Flt. Lt. Rajan Dhall Hospital
New Delhi 110070

2. “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”

3. COLLOIDS
NATURAL
Albumin
SYNTHETIC
Gelatin
Starch
Dextran

4. STARCH

5. SYNTHETIC COLLOIDS
10% Pentaspan 250/0.45
6% Hespan 450/0.60
6% Voluven 130/0.40

6. Classification of Strarch
Concentration
Molecular weight
Degree of substitution
C2:C6 ratio

7. Concentration= Oncocity
Plasma- 25 mmHg
10% Pentaspan- 80 mmHg
6% Voluven- 26 mmHg

8. Molecular weight
HES are polydispersible substances.
They contain a distribution of molecular weights.
The number on the package is the average

9. Molecular weight
After infusion the molecules are broken down by
endo‐ amylases.
If their size is below the renal threshold, they are excreted.
Excretion of smaller particles continuously reduces osmotic
effectiveness of infused solution.

10. Molecular weight
Low MW solutions have more molecules per volume.
This gives them a greater oncotic effect.
Also gives them less persistence in plasma

11. Molar Substitution
This is where the drugs derive their name
0.6 = Hexastarch
0.5 = Pentastarch
0.4 = Tetrastarch

12. Molar Substitution
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

13. C2:C6 ratio
Proportion of molecules that are hydroxyethylated
at the C2 vs C6 position.
A higher C2:C6 ratio results in longer intravascular half life.

14. Adverse effects of colloids
Hemostatic
Dermatologic
Renal

15. HEMOSTATIC EFFECT

16. HEMOSTATIC EFFECT
Seems to be more pronounced with the slowly degraded
starches.
Predominant effect is on vWF:VIII.
Some platelet effects, but these are non‐ significant

18. Multicenter randomized trial
Patients with severe sepsis
intensive insulin therapy or conventional insulin therapy
10% pentastarch HES 200/0.5 or modified Ringer’s lactate
for fluid resuscitation.
HES was harmful, and its toxicity increased with accumulating doses.

23. 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
The primary outcome was death within 90 days.
Secondary outcomes included AKI and failure and treatment with
renal-replacement therapy.
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.

27. 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)

29. Multicenter randomized trial
Patients with severe sepsis
fluid resuscitation in the ICU
6% HES 130/0.42 (Tetraspan) or Ringer’s acetate
The primary outcome measure was
either death or end-stage kidney failure (dependence on dialysis) at 90 days after
randomization
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

33. In all these studies
There was no/ little difference in
Resuscitation volume of
Colloid and Crystalloid
( 1:1 to 1:1.5)

35. methods
We randomly assigned patients admitted to the ICU
Fluid resuscitation with
4 percent albumin or normal saline .
The primary outcome measure was death from any cause during the 28-day
period after randomization.
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

38. Post hoc follow-up study of patients
with traumatic brain injury who were enrolled in SAFE study
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.
Conclusions
Fluid resuscitation
with albumin was associated with higher mortality rates
than was resuscitation with saline.

40. 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

41. 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).

42. JAMA 2013
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
Colloids ( gelatins, dextrans, hydroxyethyl starches, or 4% or 20% of albumin)
Vs
crystalloids (isotonic or hypertonic saline or Ringer lactate solution)
Conclusions
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.

43. Evidence Based Medicine
Involves caring for patients based upon
explicit integration of pathophysiology, clinical experience
And the
best available evidence,
adapted to each individual and the local health care setting
Luciano Gattinoni

44. So
Evidence Based Medicine
Should not kill
the
Medical Reasoning
Luciano Gattinoni

45. “The world is a dangerous place, not because of those who do
evil, but because of those who look on and do nothing.”
Albert Einstein
“You are not only responsible for what you say, but also for what you
do not say.”
Martin Luther King