A topic dear to my heart.

[Veneficus]

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

Ole Bayer, MD; Konrad Reinhart, MD; Matthias Kohl, PhD; Björn Kabisch, PhD; John Marshall, MD; Yasser Sakr, MD, PhD; Michael Bauer, MD; Christiane Hartog, MD; Daniel Schwarzkopf; Niels Riedemann, MD

Authors and Disclosures

Posted: 09/14/2012; Crit Care Med. 2012;40(9):2543-2551. © 2012 Lippincott Williams & Wilkins



"Abstract

Objective: To assess shock reversal and required fluid volumes in patients with septic shock.
Design: Prospective before and after study comparing three different treatment periods.
Setting: Fifty-bed single-center surgical intensive care unit.
Patients: Consecutive patients with severe sepsis.
Interventions: Fluid therapy directed at preset hemodynamic goals with hydroxyethyl starch (predominantly 6% hydroxyethyl starch 130/0.4) in the first period, 4% gelatin in the second period, and only crystalloids in the third period.

Conclusions: Shock reversal was achieved equally fast with synthetic colloids or crystalloids. Use of colloids resulted in only marginally lower required volumes of resuscitation fluid. Both low molecular weight hydroxyethyl starch and gelatin may impair renal function."


The article speaks for itself.

I was just wondering on the mechanism of AKI though. I have a few ideas but will not bore you with the details.

This is the perfect example of a treatment that can be initiated by EMS persons which will cause a negative patient outcome after EMS contact with the patient has ended that somebody else has to try to deal with.

 

[NYMedic828]

Isn't the purpose of te article to determine if colloids or crystalloids were more effective in fluid resus of septic patients?

I don't quite understand what pertains to EMS, atleast here we don't use colloids which it says may impair renal function?

 

[Veneficus]

Isn't the purpose of te article to determine if colloids or crystalloids were more effective in fluid resus of septic patients?

I don't quite understand what pertains to EMS, atleast here we don't use colloids which it says may impair renal function?

Because of the copyright policy I cannot post the full article. But the conclusion in the abstract is very humbly stated.

That is common in research papers to avoid overstating your position or initiating personal conflicts with other researchers.

The increase of AKI (acute kidney injury) is significant.

For many years EMS providers have debated whether or not they should be using crystaloid or colloid and which is better for the patient.

Many of the conclusions of not adopting synthetic colloid were based on cost analysis. With the numbers showing no significant differences in outcome between the two.

This study not only shows no difference in acute resuscitation, but also links AKI to synthetic colloid after day 5 of therapy.

A treatment that over the long term linked to harm even in this small population of 50, makes an even stronger case against the use of synthetic colloid in the prehospital and hospital environments.

Additionally, military medics use colloid because of the difference in weight.

While the mechanism is of special interest to me, the take home message is that the difference between the agents is more than just cost and weight. It actually makes a difference in outcome.

 

[Pavehawk]

There is a push by some agencies (and medics) to use starch based volume expanders in the field. This is probably what Vene is alluding to. Here is some info on it if you have not seen it before.

www.fda.gov/BiologicsBloodVaccines/.../ucm082778.htm

 

[NYMedic828]

Gotcha. That's what I thought the point was but was uncertain.

Most people in EMS just assume "we should have colloids because we need to make the BP high real fast for no reason."

 

[VFlutter]

I just read the whole article, definitely worth reading if you can get a hold of it. I love having access to Ovid/Lippincott journals.


Good luck convincing most EMS systems to look at long term patient outcomes over cost. I think it would be a hard sell regardless of supporting data.

 

[Jambi]

What's everyone's opinion of judicial/low volume use of hypertonic solutions in resuscitation?

 

[bigbaldguy]

I was under the impression that this was old news. Didn't the military already prove that this was a bad idea?

 

[mycrofft]

Thanks Vene

Before my time plasma was used by military medics.

 

[Veneficus]

What's everyone's opinion of judicial/low volume use of hypertonic solutions in resuscitation?

My opinion is...

complicated...

Really it is patient specific.

Better used in head injury and while it is said it can be used without a working kidney, I don't know too many people who believe that.

It is a good tool, but not really for prime time outside the ICU.

 

[RocketMedic]

Cost-wise, I believe crystalloids will always be cheaper than colloids.

They are also far more versatile. For instance, Hextend is not appropriate for treatment of dehydration.

The military has stepped away from colloids due to cost, patient outcomes, and an inability to correctly train medics on its use.

 

[Veneficus]

Cost-wise, I believe crystalloids will always be cheaper than colloids.

They are also far more versatile. For instance, Hextend is not appropriate for treatment of dehydration.

The military has stepped away from colloids due to cost, patient outcomes, and an inability to correctly train medics on its use.

That is very interesting.

When did that start?