ColloColloïïdesdes--CristalloCristalloïïdesdes::le point en 2005le point en 2005

FrFrééddéérique rique SchortgenSchortgenrrééanimation manimation méédicaledicale

hôpital Henri hôpital Henri MondorMondor--CrCrééteilteil

Colloids withCrystalloids

n=312 (65% )

Colloidsn=173 (18%)

Crystalloidsn=92 (17%)

Justifications of plasma expander choice:Justifications of plasma expander choice:The most frequently cited arguments

Colloid users n=4771) The rapidity to reverse intravascular volume loss 96%2) The choice of volume expander is strongly

dependent on the clinical situation 81%3) The long lasting volume-expansion effect 66%4) The reduced risk of pulmonary oedema 49%

Colloid nonusers n=991) The low risk of adverse events 92%2) Crystalloids are as effective as colloids

if the volume administered is sufficient 90%3) The low cost 86%

Pourquoi utiliser un colloPourquoi utiliser un colloïïde? de?

EfficacitEfficacitéé pour un moindre volumepour un moindre volume

Haemorrhagic shock

Amount of fluid required5% albumin 18.6 ± 2.3 mL25% albumin 7.6 ± 1.4 mLRL group 63.5 ± 6.0 mL

Endotoxic shock

Amount of fluid required5% albumin 11.6 ± 0.7 mL25% albumin 5.1 ± 0.3 mL RL group 50.2 ± 2.7 mL

Zhang et al. Crit. Care Med. 2003

1 : 3 RLPentastarch

Increase in Blood Volume: 500 ml

SurgeryUeyama1999

1 : 1.6RLHES 10%

PAPO 16-18Critically ill patientsHankeln1989

1 : 2.9RLDextran 60

PAOP maintenanceVascular surgeryDawidson1991

1 : 1.7RLAlb 5%

PAOP and CI maintenance

Vascular surgeryVirgilio1979

1 : 1.9RLPlasma

PAOP maintenance Vascular surgeryShires1982

1 : 1RLAlb 5%

PAM>80 mmHgTrauma+chocMoss1981

1 : 1.4 to 2NSHetastarch5% alb

250 ml/15min until PAOP 10-15 mmHg

Hypovolemic shockHaupt1982

1 : 1.8 to 2.4NS Hetastarch5% alb

250 ml/15 mins until PAOP 15 mmHg

Septic shockRackow1983

Colloids :Crystalloids

FluidsobjectiveIndication

30 hypovolemic septic shock (ITBVI<850 ml/m2)

250 ml bolus4% Gelatine 35 kDa

250 ml bolus6% HES 200 kDa/0.62

ITBVI>900 ml/m2 ITBVI>900 ml/m2

750+274 ml 714+254 ml

ITBVI=798+37 ml/m2 ITBVI=791+52 ml/m2

Pourquoi utiliser un colloPourquoi utiliser un colloïïde? de? Pour prPour préévenir lvenir l’’oedoedèème pulmonaireme pulmonaire

AA

πmvPmv

Ppmv πpmv Qf

Qf = Kf [(Pmv-Ppmv) - σ(πmv-πpmv)]

EffectsEffects of of albuminalbumin supplementationsupplementationon on microvascularmicrovascular permeabilitypermeability in in septicseptic patientspatients

Michael P. Michael P. MargarsonMargarson andand Neil C. Neil C. SoniSoni Vol. 92, Issue 5, 2139Vol. 92, Issue 5, 2139--2145, May 20022145, May 2002

ALB 20%200 ml (90sec)

AlbuminAlbumin andand furosemidefurosemide therapytherapy in in hypoproteinemichypoproteinemic patients patients withwith acute acute lunglung injuryinjury

GS Martin GS Martin CriticalCritical Care Care MedicineMedicine 2002; 30(10):21752002; 30(10):2175--21822182

- 930 €

30 hypovolemic septic shock (ITBVI<850 ml/m2)

250 ml bolus4% Gelatine 35 kDa

250 ml bolus6% HES 200 kDa/0.62

ITBVI>900 ml/m2 ITBVI>900 ml/m2

750+274 ml 714+254 ml

ITBVI=798+37 ml/m2 ITBVI=791+52 ml/m2

0

200

400

600

800

1000

1200

BL End 30 min 60 min0

2

4

6

8

10

12

14

16

18

20

ITBVI-HESITBVI-GelEVLW-HESEVLW-Gel

ITBVI, ml/m2 EVLW, ml/kg

Molnar et al. Intensive Care Med 2004

Effects of albumin and Ringer's lactate on production of lung cytokines and hydrogen peroxide after resuscitated hemorrhage and endotoxemia in rats Haibo Zhang, MD, PhD; Stefanos Voglis, BSc; Chang-Ho Kim, MD; Arthur S. Slutsky, MD 2003; 31(5):1515-1522

Cytokines pulmonaires

Twenty-five percent albumin prevents lung injury following shock/resuscitation

Kinga A. Powers 2003; 31(9):2355-2363

Sham

ALB 25%

RL

ALB 5%

EffectsEffects of of albuminalbumin supplementationsupplementationon on microvascularmicrovascular permeabilitypermeability in in septicseptic patientspatients

Michael P. Michael P. MargarsonMargarson andand Neil C. Neil C. SoniSoni Vol. 92, Issue 5, 2139Vol. 92, Issue 5, 2139--2145, May 20022145, May 2002

Comparison before and after 40-g albumin infusion

Preinfusion Postinfusion Pvalue

Albumin, g/l 9.9 ± 3.9 18.3 ± 4.1 (at 30 min) <0.001

CVP, mmHg 11.2 ± 3.3 13.2 ± 3.6 (at 30 min) <0.001

TER, %/h 6.6 ± 1.5 6.1 ± 2.2 0.406

t1/2 of 125I-albumin min 571 (Median) (95% CI 545-752) 672 (Median) (95% CI 575-918) 0.511

Restrictive

Libre ImprovedImproved outcomeoutcome basedbased on on fluidfluidmanagement in management in criticallycritically illillpatients patients requiringrequiring pulmonarypulmonary

arteryartery catheterizationcatheterization

Mitchell et al. ARRD 1992

2004;350:2247

RCT6997 patients

18 months16 ICUs

2004;350:2247

RCT6997 patients

18 months16 ICUs

N Engl J Med 2004; 350: 2247

Patients with trauma andan associated brain injury

0

5

10

15

20

25

30

Saline Albumin

Mortality (%)P=0.009

CrystalloidsCrystalloids vs. vs. colloidscolloids in in fluidfluid resuscitationresuscitation: : a a systematicsystematic reviewreview..

All StudiesAll Studies

1515

Studies in traumaStudies in trauma

55

nn

732732

302302

0.86 (0.630.86 (0.63--1.17)1.17)

0.39 (0.170.39 (0.17--0.69)0.69)

11 22 55 1010 2020 5050 100100.5.5.2.2.1.1.05.05.02.02.01.01

Favors ColloidsFavors ColloidsFavors CrystalloidsFavors Crystalloids

Choi PT et al. CCM 1999Choi PT et al. CCM 1999

0

200

400

600

800

1000

1200

1400

1600

Day 1 Day 2 Day 3 Day 4

AlbuminCrystalloids

Liters

1:1.4

SAFE N. Engl. J. Med. 2004; 350: 2247

Impact of fluid choice on the outcomeof critically ill patients with shock

F. Schortgen, S Bastuji-Garin, N. Deye, L. BrochardMedical ICU and Public health

Henri Mondor HospitalCréteil-France

Methods

• Prospective cohort study

• Consecutive adult patients admitted in 115 ICUs (30 countries) during a 4 weeks period and needing fluid resuscitation for shock in the intensive care unit

736 patients with shock

611 receiving colloids 125 receiving crystalloids

% of patients

100Type(s) of colloids administered

80

60

40

20

0Starches Gelatins Plasma Albumin Dextrans

Risk factors for acute renal failure:multivariate analysis

Renal organ failure at inclusion

Diabetes

ARDS at inclusion

Volume of fluids (first 36h) > 8.4 L

High doses of vasoactive drugs at inclusion

Male gender

SAPS II at inclusion > 50 points

Indication of fluids: Sepsis

Trauma

Others

Use of colloids

ORFavour ARF

Adjusted OR, p

3.83 (1.81-8.13), <0.0001

2.36 (1.23-4.51), 0.01

2.34 (1.29-4.27), <0.01

2.16 (1.42-3.28), <0.001

2.02 (1.28-3.19), <0.01

1.79 (1.15-2.79), <0.01

1.72 (1.12-2.64), 0.01

0.95 (0.62-1.48)

0.31 (0.12-0.78)

1 0.02

1.97 (1.05-3.69), 0.03

1 2 4 6 80 3 5 7 9

Renal organ failure at inclusion

Diabetes

ARDS at inclusion

Volume of fluids (first 36h) > 8.4 L

High doses of vasoactive drugs at inclusion

Male gender

SAPS II at inclusion > 50 points

Indication of fluids: Sepsis

Trauma

Others

Use of colloids

ORFavour ARF

Adjusted OR, p

3.83 (1.81-8.13), <0.0001

2.36 (1.23-4.51), 0.01

2.34 (1.29-4.27), <0.01

2.16 (1.42-3.28), <0.001

2.02 (1.28-3.19), <0.01

1.79 (1.15-2.79), <0.01

1.72 (1.12-2.64), 0.01

0.95 (0.62-1.48)

0.31 (0.12-0.78)

1 0.02

1.97 (1.05-3.69), 0.03

1 2 4 6 80 3 5 7 9

Risk factors for acute renal failure:multivariate analysis

Renal organ dysfunction at inclusion

Diabetes

ARDS at inclusion

Volume of fluids (first 36h) > 8.4 L

High doses of vasoactive drugs at inclusion

Male gender

SAPS II at inclusion > 50 points

Indication of fluids: Sepsis

Trauma

Others

Use of starches

Use of plasma

Use of albumin

ORFavor ARF

Adjusted OR, p

3.73 (1.75-7.97), <0.0001

2.12 (1.10-4.10), 0.03

2.29 (1.25-4.20), <0.01

1.88 (1.22-2.91), <0.01

1.97 (1.24-3.14), <0.01

1.81 (1.15-2.85), <0.01

1.79 (1.16-2.76), <0.01

1.05 (0.67-1.64)

0.33 (0.13-0.85)

1 0.02

1.57 (1.03-2.39), 0.04

1.66 (1.06-2.61), 0.03

1.76 (1.02-3.04), 0.04

1 2 4 6 80 3 5 7 9

Renal organ dysfunction at inclusion

Diabetes

ARDS at inclusion

Volume of fluids (first 36h) > 8.4 L

High doses of vasoactive drugs at inclusion

Male gender

SAPS II at inclusion > 50 points

Indication of fluids: Sepsis

Trauma

Others

Use of starches

Use of plasma

Use of albumin

ORFavor ARF

Adjusted OR, p

3.73 (1.75-7.97), <0.0001

2.12 (1.10-4.10), 0.03

2.29 (1.25-4.20), <0.01

1.88 (1.22-2.91), <0.01

1.97 (1.24-3.14), <0.01

1.81 (1.15-2.85), <0.01

1.79 (1.16-2.76), <0.01

1.05 (0.67-1.64)

0.33 (0.13-0.85)

1 0.02

1.57 (1.03-2.39), 0.04

1.66 (1.06-2.61), 0.03

1.76 (1.02-3.04), 0.04

1 2 4 6 80 3 5 7 9

RiskRisk factorsfactors for ARDS: for ARDS: multivariatemultivariate analysisanalysis

Volume of expander > 1.3 L/d

X ray score > 2

Sepsis as indication of fluids

SAPS II > 50 points

Use of colloids

Age > 63 years

Adjusted OR, p

9.03 (4.30-18.90), <0.0001

4.36 (2.42-7.84), <0.0001

1.49 (0.84-2.65), 0.17

1.25 (0.70-2.25), 0.45

1.19 (0.51-2.78), 0.68

0.51 (0.28-0.93), 0.03

OR

Favour ARDS

1 2 4 60 8 10 12

Risk factors for mortality:multivariate analysis

SAPS II at inclusion > 50 points

Fatal underlying disease

High doses of vasoactive drugs at inclusion

Medical admission

Volume of expander (first 36h) > 3.7L

ARDS at inclusion

Use of colloids

Adjusted OR, p

4.89 (3.40-7.03), <0.0001

2.09 (1.45-3.00), <0.0001

1.81 (1.20-2.75), < 0.001

1.74 (1.16-2.62), <0.01

1.53 (1.06-2.21), 0.02

1.73 (0.98-3.06), 0.06

1.57 (0.97-2.55), 0.07

ORFavor mortality

1 2 4 60 3 5 7

SAPS II at inclusion > 50 points

Fatal underlying disease

High doses of vasoactive drugs at inclusion

Medical admission

Volume of expander (first 36h) > 3.7L

ARDS at inclusion

Use of colloids

Adjusted OR, p

4.89 (3.40-7.03), <0.0001

2.09 (1.45-3.00), <0.0001

1.81 (1.20-2.75), < 0.001

1.74 (1.16-2.62), <0.01

1.53 (1.06-2.21), 0.02

1.73 (0.98-3.06), 0.06

1.57 (0.97-2.55), 0.07

ORFavor mortality

1 2 4 60 3 5 7ORFavor mortality

1 2 4 60 3 5 7

Experts recommendations

SCCM 2004SCCM 2004Isotonic crystalloids or iso-oncotic colloidsare equally effective when titrated to thesame hemodynamic end points.

SurvivingSurviving SepsisSepsis CampaignCampaignUse crystalloids or colloids.

ATSconsensus statement

For a same pric€ in 2005...

79 L

9 L4 L

0.5 L

ALB 4% Starches Gelatin Saline