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Evidence summaries

Colloids Versus Crystalloids for Fluid Resuscitation in Critically Ill Patients

Resuscitation with colloids appears not to reduce the risk of death, compared to resuscitation with crystalloids. Furthermore, the use of hydroxyethyl starch appears to increase need for blood transfusions ja renal replacement therapy. Level of evidence: "B"

The quality of evidence is downgraded by study limitations (unclear allocation concealment in 54 of 78 studies).

Colloids are not recommended for fluid resuscitation in critically ill patients.

The recommendation attaches a relatively high value to possible increase in mortality and high cost of colloids compared to crystalloids.

Summary

A Cochrane review [Abstract] 1 included 69 studies with 30 020 participants comparing colloids to crystalloids in patients requiring volume replacement. There was no clear evidence that colloids (starches, dextrans, gelatins, and albumin) reduce the risk of death, compared to crystalloids, in patients with trauma, burns or following surgery (table T1, T2, T3). Hydroxyethyl starch slightly increased the need for blood transfusion and renal replacement therapy (table T1).

Starches compared to crystalloid for fluid resuscitation

OutcomeRelative effect(95% CI)Risk with crystalloidsRisk with starches (95% CI)Number of participants(studies)Certainty of the evidence
All-cause mortality (at end of follow-up)RR 0.97(0.86 to 1.09)233 per 1000226 per 1000(201 to 254)11 177(24)Moderate
All-cause mortality (at 90 days)RR 1.01(0.90 to 1.14)238 per 1000241 per 1000(214 to 272)10 415(15) Moderate
Transfusion of blood productsRR 1.19(1.02 to 1.39)299 per 1000356 per 1000(305 to 416)1917(8) Moderate
Renal replacement therapyRR 1.30(1.14 to 1.48)82 per 1000106 per 1000(93 to 121)8527(9) Moderate

Albumin and fresh frozen plasma compared to crystalloid for fluid resuscitation

OutcomeRelative effect(95% CI)Risk with crystalloidsRisk with albumin (95% CI)Number of participants(studies)Certainty of the evidence
All-cause mortality (at end of follow-up)RR 0.98(0.92 to 1.06)254 per 1000249 per 1000(234 to 270)13 047(20)Moderate
All-cause mortality (at 90 days)RR 0.98(0.92 to 1.04)259 per 1000254 per 1000(239 to 270)12 492(10) Moderate
Transfusion of blood productsRR 1.31(0.95 to 1.80)290(3281 per 1000368 per 1000(267 to 506)290(3) Very low
Renal replacement therapyRR 1.11 (0.96 to 1.27)201 per 1000223 per 1000(193 to 255)3028(2) Low

Dextran and gelatin compared to crystalloid for fluid resuscitation

OutcomeRelative effect(95% CI)Risk with crystalloidsRisk with intervention(95% CI)Number of participants(studies)Certainty of the evidence
Dextran: All-cause mortality (at end of follow-up)RR 0.99(0.88 to 1.11)237 per 1000235 per 1000(209 to 263)4736(19) Moderate
Dextran: All-cause mortality (at 90 days)RR 0.99(0.87 to 1.12)258 per 1000256 per 1000(225 to 289)3353(10) Moderate
Gelatin: All-cause mortality (at end of follow-up)RR 0.89(0.74 to 1.08)301 per 1000268 per 1000(223 to 325)1698(6) Low
Gelatin: All-cause mortality (at 90 days)RR 0.89 (0.73 to 1.09)334 per 1000298 per 1000(244 to 364)1388(1) Low

An analysis 2 of a nationwide trauma registry in Germany included 48 484 patients with mean age of 49 years and mean injury severity score of 23 points; 72.3% were male and 95.5% had blunt trauma. Risk-adjusted analyses revealed that patients receiving over 1 000 ml synthetic colloids experienced an increase of renal failure and renal replacement therapy rates (OR 1.42 and 1.32, respectively, both p HASH(0x2f830d0) 0.006). Any synthetic colloid use was associated with an increased risk of multiple organ failure (p < 0.001), but there was no effect on hospital mortality (p = 0.594).

Clinical comments

Note

Date of latest search: 2020-01-04

References

  • Lewis SR, Pritchard MW, Evans DJ et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev 2018;(8):CD000567. [PubMed]
  • Hilbert-Carius P, Schwarzkopf D, Reinhart K et al. Synthetic colloid resuscitation in severely injured patients: analysis of a nationwide trauma registry (TraumaRegister DGU). Sci Rep 2018;8(1):11567. [PubMed]

Primary/Secondary Keywords