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Crystalloids,olloids,blood, loodproductsandblood ubstitutes

Thechoice f fluid n a given lnkaLs.enaioclies n knowLdsef hephy5 logyandphamacologyf the fluid.A broad ange f fluidsarcdG.ussedn lhis arlkL,wlth paftkular mphasis n problems sso.laled wth ex.ess dministrauonf 0.94l. aline. oLLoids,Lood, Loodp@du.ls ndbloodsubstitutes realsodis.ussed. alaicinghe nsksof allogeni. lood ran+uslonor a palientand hnsfuson thrcsholdsate consldered.he potenrial f haemosLobinubslilutes rc stiLl elro be rcaLlzediowever olyHemes curently n a phase pre.hospital

Keysords ani6cial acmoglobin5:loodpoducls! olLoids;ryslaLloidsr

There rc maDy luidsavailableor nrlravenousdninisrr:rion.Thcy arenorDrlly caleSoozedscrynalloids r colloids. fullundcGrandin8tlhe clinical ce.ario, le pharmacolotyt thesolurion nd fluid dislriburionn lbe body n boih normalandabnomrl physiologyreessenrialor choosjnghc mosrappro-piatc llujd The physjology I fluid rcplac.Dcnt s discussedin Anaesfhesidnd nrensiupare medicine :21 7-9. All l\tidscause n initial expansion f $. intravasculrr omparlment'fhe durarion l thisilecrdepnds n how freely he luid canmove ncioss he vasculd endolheliun.The composition fsonre onnonly used nrravenousluids s show i Table1crystalloldsCrystalloidsre solulions I srnall onic or non oNc parriclcsrhar anpasshrough semi'pernablenbranewhcnin solu-tion lhese solLrlionsave diilerentconccntrationsl sodiumchloide and orhersalts,and some olurions ontaina folm ofbicarbonarerecureor,uchas actate.Dexrrose oluliondoesnorconlain odium hlotdeorother alts, nd ls adnrnrstralronis a convcnicnt ay ol Eivin8 patient reewatef o allow he

Donl.l LN, rtckr,Ft^ is SpeciolistRegistrur n Anaestheea natistol. He quolifiedJton the uni@6iry ar No\inghan i4 1997 dndtrained n pdediohcs. His resear.h nletests nctude nedicol edu.olion

I.hdel Miln., q hs tuk a*c..ca is consultont n anoesthesioondthtensivecote at Nadh aristol NHs ttust. Hequolifed lron canb dqein 1933 and ttuined in southoaptan ond ansbl, His nte ests ncludelosculat ond neurcvosculotanoestheticcote.

excrerion fi sodjlm oador to slowly chydrar. hypemarae

0.9%Sodium hloride saline)s ndicalcdn sodiuD epleton,which mry arhe froD condnjons uchas diabetic toacidosis,ilcus, ascilcs r gastrcentedlis.t has a calculaled smolarilyof 308mosDolc/k6:he measured smolarilys sli8hrly owerbecausconsdo nol complerelyissociale. life of 0.9%salincSiveno a 70 kE ndividualwill dislriburenlo an odracellularfluid ECF) ompanmenrl r4lifes,leavjnS maximunr i 35%of headministeredalinenrhe ntravascularspace.hlls3 lilrcsof 0.9%NaClare cquired o Gplac achife ol blood oss.0 9% NaCl sconmonly,althoughncone.rly, allcdnormalsaline. he erm'normaldoes ot mplyphysiologicalappropri-dten.ssA normal solutionmcans molarsolution i. I lilrcof solution onlains nolc of thc solute) For Nacl a I moldrsolutionwould contain 8 sE Nacl per itre (molecular eiEhlN!,23r Cl ,35.5) . hc ol lowin8 alculat ionenonstralesheaclual onrcnt i 0.9%Nacl solurlon:. 09% NaCl 0.98 NaCl n r00 nl waleror 9I NaCl n1000 lwatr .. SincesS.sg l dolei9/s8.s 0. ls4molcs l Nacl n I l i l r .solution 154mmolsolutionn 0.9%salinc.0.9%NaCl s oflen napproprialelysed.A few itrescausehypcrcoaSulabletate nda hyperchloraemicelabolic cidosis.In the poslopcrativeetlin6,where he stressesponse ncouraSeshebodylo elain odiunandhen.ewaler, rcessivescof0.9% NaCl an .iseseru osmolarily ndcausluidolenoad,Pulnonary edemaanoccurildere sa brcakdownncapillarypelmerbiliry r inpai.ed elt leDtricular unc[on.sevcralpm'rpecliveardonizedsrudies avecomparcdhccf{cdsof 0.9%NaCl nd balancedahbasedluidssuch s Hrrrmann solurion,and have oDndErearerdnaryoueut in parienisreatedwi$balancedal rbased oluaons.n a p.ospective,ndomized ndblindd tudyof 200cardiac urg'cal aticnrs ho received ormal salinc-basedydroxyethyllarch HESI, alancedaltLIDS,Haltmann or nolmalsalinc ased % albumin olution s heirinrraopetariveluid rherapy,hose atientsreared ith nornialsaline.basedluldshadsiEnificantly orse enal unclionwirh ahi8lrcr eq{nemenlor posroperativeialysishan hose iearedwilh balanccd r1t-basedolulions.Posr.salinecidosis asbeen ecognizedince1923.WhetheLacidosiss caLrsedy byperchloraemiaheDcehe renrrhypcr.chloraemic cidosisl r whethr h snnplya netabolic cjdo.sisassocilld nh lyperchloraemias under ontinucd cbarc.Recenr ork hasextendedar slykebhypolhesisrom l9lz. )Electroneutlalitys a relatively ewconceptn acid-baseheorylanions, aniculadychloridc,areconsideredasacids;ndcarions,palticularlyodium, sbases.Inhisbiocbemicalmodel,hesizcol thcdifferencen charEeberweenrronSlyhareedations ndsrronSlyhar8ed;riohss rlroughl Dhf|!enceacid-baserarus.Re$rdless f lhe oulcome f this debare, ypdchloracmiaanciuse enalvasoconstricdonnda decrcasen 8lomcruldrilrh

Hanmann's $lurion (Ringer's actate) s a balanced allsoluion that has a coDpos on sinilar ro EcF.FormularedySydney in6cr or use n paediarric etabolic cidosis, is rhecrystalloid t choice or ECF eplacedenr,hh solulion s also

8/6/2019 Colloids Crystal Lo Ids and Blood Expanders

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Composit ionI some

11.0

111.0 t .0150.0

5.1

Chbnd. Bi6r6onate

3 1 -

111.0 29 (la.talel

1A5 PoLypeptides1)0 125 0H peptides

279230.0

mosmol4l .onstituenteE! l

album a.ry. solution)

4.5-5.5 lO8

Gluco* t07 .4

100-160

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beltr ndicator f perfornances lbenumber velaEe olcuarwei8ht, iven he designation Wr, which canaccounl or rhedistribution t weiShrs nd nor ust an averaEe.n addnion orheMWn, he onic cha!6e f thepalticles nd hepermeabilityoi rhevascular Ddothcliumo lhe colloid nflunceslonSevityoI thesolurionn the nllavascular ompartmenr,Gelalins (cloltrsim and lt@macceo contain modifiedBelarinsbcrween0 ,nd 35 lDa Mwn. They hdveno oxy8en.cdrryingability, half ileof 3hou6 n thecircularionnda sDall 0.4%)dskofallerSiccactions.leyhavcno clinicalcllccl n coa8ulation,excepthaicaused y hacDodilurion.Hydroxyelhylslarch (HES)solutionconpriseshydrcxyethylelhedfied mylopdinmolecules.heirprope es varyaccord-in8 o heirconcentrarion,olecular cighlandxtnr fhydrox'ylationor subslilution. hey hav an intravascularall-lifeoI24 hou6,andarehydrolysedy amylasentosmallcrmolecules.Those ith a Mw ofle$ than50kDaare enally xcrered.Dy-laseaction s supprc$ed y hi8her evelsof subslituionandwithErealer lherificaton t thC2 rarher han hC6positioHES anplugcapillaryealtsnduccd y sepsis M trauna,andfenoremacropla8cuncliorafrefhaenofhaSic hock.HES an causc coaguloparhy,hich s thouthl lo be ducro depressedlarelel lncrion sccondaryo diminished onwillebrand acto! (vwF) antiEen. notherexplanationor thhcoa8ulopathy thal saljN basedHESpreparationso not ontain becahium equiredor platclel crivation nd he unctionof rheplarelet PIIb/llla eceplor,which binds iblinogen nd

Otherside efieds of HES nclude ntractable rurilisandexrravasationniurics. HEs does nol inrerterc wirh bloodDert.ais arederivcd rom lhe acion ot lhe badcrium koroslo.mentetuideson a sucrose edilD via rhe enzymedext.ansuffaseTheprcdudh a 6roupof branchedolysaccharidesf200.00061uco\en.rs he\e nJerSodnidlh\drol)s i :oprodJrenoleculcslmeanMW40,60,70nd 10kDaDextran 0 is hyperoncolic nd initially ads as a plasmaexpander efore rs rapideliminarion y the kidncys. ts mainuso s for prcmotinS eripheral lood low {in prophylaxisordeepvein thronbosis nd n maintainin8 raltpatencyn flapsuEery). mprovementr blood low occurs ecausf a rduc-rion n plasma iscosityndpossibly y reducinShe nreractio|bctweenhevascular ndolhelium nd rhecellular omponenBof blood.Dexuans educeplatcletadhes'veness,nhanceibr inolyshand.yreducactorVl l l lct ivny.osesabove.s8lk8ploduc coagulopathy odern extrans o not nterfere ithblood (os$Darchin6.Renal ubular obstruclionDay occurbecause f dexlran asts. naphylaxisanoccur l/4s00)Iromprcvious ross'immunizationSainst aclerial nli8ensomin8dcxlran'reactivenribodies,Blood ndbloodploductsBlood s obtained rom volunteer onationwirhin rheUK. Th.admininrarion f rhisprocesseslswilh lhe NarionalBloodScrvice, special ealrh Lrthoriryf lhe NHs. Cunently resh-frozenplasna (FFP) reaiedwirb nethylenblue for viral

53

inactivations sourcedion the USA.This is bccause i rherisk oI transmilring rion elatcd ew variantCrcutzfeld-Jakobdiseaseia tHnsf sion.ln acul. blood oss, esuscirationirh lreshwholeblood sthe deal eplacemntecausct hasoxygen'caryin8bilityandcxpandshe ntravasculdompaltment.h ranstusionhresholdhasbeen n a Sradualecline urinShepast wo decades,hichhasbeeopromprcd y satetyconccm reEardin8 Mn the 1980s.The decision o ftnstuse a palicnl nads io bala.ce the nsksolvaryingeveritiesI anaemiand he isl{lofallogcnicraNtusion.Balancingbks of allogenicranstusion:llbloodprcductsarryrisls oI inlection with known and unlnown Bcnc. Risk arereducedwith sceening, chemicaland hea rearmcnr,but are noteliminated.lood rcducc lso arry hensksofanaphylards.heriskoi bacterialontaninations hlghst ith thc useoi phrelersbccauseheyarestor.dat rcom emperatureBO nconpatibililyol RBcploducls Dd rasfusionielatedunB njuryFMLI) arclhecommoneslpecificisks f rr.Nfusion. RALI san mDune-Dcdiared onditionmediated y anribodi.s D the rranslusedplasma. ratl.vecu$hoslneasc a delayedransflsioneactionof donorBranulocyresgainstccipicntissues.hcdskol hisdiscasehas een educedy routnc cucodeplerionfdonated lood.ln lheTRICCrial (T.ansiusionequnemen$nCntiqlCare)6838parients ererandonlyallocaredo a renrictive r liberaltransfusionuatcgy. he estrictivroup ere ransiusedl hae-moSlobincvch ol 7 g/dl, thc liberalgroupwcre anstusd tlo8/dl.Thc30dayno(ality wassli8huyowcr n the esricliveEroup 18.7ve6us23.3%).subgloup nalysis f patienrs ithcardiovasdlar iseaseid nol 5howany diffcrencen mo alilybetweenhe wostmle8ies.Bloods collecledron donorsnroan anricoa8ulanl,onmonlyCAPD (cirrale, denine, hosphale nd dextrosel. unir oiwholeblood asavoluneof400-450ml.Ir is tcsredorcommonseriousransmissibleirusesiDcludirg lv, hepalilis andC).Mosrunitsar. centrifu8cdo separareur rh! conponenl ans,leavin8 50ml oi packd BCSlussupematant ACMis salineprese.vativeontaininEaline, dnln, lucosnd nannilol,and 00ml s added o thepnckedRacs o increasehevolumclo 350Dl and o Eivea haemalocrit10.6-0.7.No appreiablecirrate r clottinEacrorseDain n thepackedelh.P{ led RBCarnbeEi \ n o ndcd\e Jr ienrsxyScndrryntcapacily.Howcvef, areshouldbc takenwhen nfusjn8 artcvolumes ecause ypothermiar low levehof 2, 3 diphospho.Elyceraleancalsea lett shift n lhe oryEen iss@iationurv,which Dpailsoxygen eliveryo tssues.RBCSanbe slored or35days r4'C or iquidnitrogcnrozen o! on8.rsroragealoodproducGr he suprnalanlron a unirof wholeblood scenrilu8ed $in ar 20'c to yield I unir of plalelelsontaininS50 70 nl of plasma, hichcanbe noredal 20-24'C or up lo5 days. Allernatively, lntel.rscan be obtained y platelcl-pherers. hich ie ld ' 6 unirs om onedonorThppadnrnSplasna s proccssednd rozcn o orm FFP. hc activ'iyol fac-torsv and Vlll arep.eservedn rhisprocess. urin8 he rapidlhawinE f FFP, 8elabnousrecipitales formed,which s richin factor ll l and ibrino6en. his s calld ryoprecipnate,ndcanbeseparared,elrczen ndsroredor up 10 yar.

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Platelels re essenlialor nomal coaguladon. ounu below50 x ]o'!/litrcarea$ocialedwith in*easdblood os duringsurgery.ounrs eloe20 x lor/litle areassociatedith spon-taneous leedinS ransiusionfplateletss ndicatedn ableed-ing palientwith rhrombocyropenia,latelerdysfundionandprophylaclicrllyefore n invasive rocedure. unil increas.srheplatelet ounl by 5 x lfllitre, and ABOcompatibilitysdsirable.ompatiblelatletsurviv or 1 7 daysand do norcausehesusensilizatjon' hacmolyriceacrjolrs,FTPcontains ll plasma rcteins. is indicar.d or coagulo-pathiesaused y solaledacror eficiencies,nriarin he.apy.liver ailureand hronbotic hfombocylopenicurpura. he ni-rialdose n adulrss l5 nl/k8. I Lrni will increasach lotingfactor y 2-3% ABOcompatibilitys dsiabl,Cy.oprecipitates esewedor severe isseminatcdnlravascularcoa8ulaton, hich csulGn consumptionfallclotling acrorscspecialiyiDrinosen.his srbstances usuauy ndicated h.nthe ibrinoSenoncentrarionallsbelow g/lil|.Albuin h a majorplasnaproteinwith a Mw of69 kDa. lbumin hclp\ ro nainrdn.ollordoncotic rcsure.prcsedesmi.rovascularnle8rity, rovidesindingand ransporlor molecul.sandaclsasa plasmauffer.Its oncentrationalls n rhecriticallyill 4.s%a.d 20%solutions reavailableor ransfusionndareLlsuallysed splasnaexpandrsathr hanasa treatmntor

Two distinctstratEiesre bein8developedn rhe searcho!an oxygn-cafiyin8loodsubstiture.ne srrategynvolves n.dvelopnent f haenoglobin-bascdxy8encanien (HBOC5)rhir lmr lhc oleol ae-o8lobin reorhernvolvsdrnin8oxyEenn a dissolvedtarc ringpe.fluoroca.bonmuhions.HanoSlobtn-basedxyge! carieK (EBoc): he deaof usingpurifidhaenotlobin nsread f RBCS as benaroundsince1916whna haemoglobinalin olulionwasusedon hunansto realannemia. owever,hisprocedfe ailed ecauselrenalroxicily aused y erythrocyiekomal ipids.Once rroma{reehaemoglobinscrc availablet became pparenlherewerestill wo mainproblns:he pudfied aenoElobin ad oo highan affinity or oxygen nd loo shon an intravascularalfliie.The HBOCS ufiendy n developmntave ben ngineer.dIo havea rduced ffiniry or oxygn nimickin8rhe effectsof 2, 3 diphosphoglycerale)nd an extended ircllalon trme.

Prevenri.g acrno8lobineramerbrcakdownasbecnachievedby tro$ linking ctradeA,deatinghaenoglobjn olymeFandcncapsulatin8aenroglobinithina lipidvsicle.Pol',Henes a cro$-linked olymer l humanhaemoglobin,in which wo or more etrame.s rc inl

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Pharmacologyf plasmaexpanders

Plasna xpandeA re rypefoncoricnd/orhyperLonicluids harexpand he cncularing lood volume o a grearer {rent$anNotoniclsooncoocluids. ypic!1Iy,olloidalsolutronsreusedto expand hepla a volutne.However, yprtonic ysralloidsolutionsho provide hort ermplasnaexpansior. heproperticsoI h. plasDu xpandos .sc bcdbclowarcsumnanzcdnTablc andFigu.cLColloids re a dlsDesion f oreanlcmolecrles l va ablemo.-J ld Freh, 'h" ld n:oh ron l po. . 'o\r le i i b; ,d ld lal-9!Lyr$r-40.-9!!-sscross he vascular ndolheliun asily, hus exerlinga colloid

osmoric re$ure (COP),vhichatfacls extravascularluid intofe i l i r ion. .ompdred l seBhl. .er .Bed mole l r lwciSht Mw\,rarilhnctjcncan) Ihenunberaveragediole.ula.weiSht Mwri mcdian)of a plaenaexpandero(elatesnorecloselywithtsduration laction In contrast,hecoP sproporao l ro e number f nolecJleor on5 I o l , .e

Albumin s a Dalurally c.urrirgplasdaprotein lumanalbu'nin solut ionHASI onlains6% albunnn, hi lsr pu. i i iedproreinraction onral$ 83% albumin,with tle renanlderasElobulin. lbumjn sderivcd .ompooled u'nanplasDa, erumor normalplacenlas,nd hen sterilized y hcaljngand ulrraiiLlraljo. o prevent isease ansml$ion Bccause i concernsregardnrgrion (ransdission, AS s sourced rom the USA.Albuminsolurions reparedrom wholebloodcontarn o crortni8 acros, bloodgroupantibodies r plasma holrnesterases:tlrereiore.looderouoine nol reduirLlThe MWrv nd MWnof II S areapproxjmalely9 kDa.ho.tonic(4 5% protcin)and oDcenrated olurions20 25%l areavailablc nfusioD I 100nl 25%HAS ncreaseshe ntravrscu-larvolume y 450nl, althoughlhh s unpredicrablenddepe^dson blood volume,serumprotclD onccnrration,apjllary ermeabilily ndexlravascnlar'ater vailabilily.FindinEsrom a recent ludyol inlcnslv.carcparicnts,onpnrinEHAS wllh saline or rcsuscnallon,howcd hal 28 daynorralitywassinilar n bothSroups.Tberefore,r is besr o uscnore cosreiiecrive llemaliveso HAs. sideelfechoi HAs arcvcry rarci thc nrcidence i anaphylacroideaclions approxi-natcly 1/1000 crycar.Celdlinsnle polypeplidesMw" 30-3skDa] produced y th.) d r n ' o ' u n ' d o r d e ' l e - o , r r r o ' p o d . . e_ r ' e d ' r n k " de d r ' . . u a e m a " e l r .u ( - i n . L l e l e d l r . r C e l .;i-;T-;?-o.ypo ]Be a r I he:;--:i?:IF-:mna" r.eD \ r o e . l d n d D . . n d v ! d 6 A p l a r n s l e a ! r ' o . t e m u \ e ,byglom{ulari luat ior ndproreasentabol ismi th inhe t iculo.ndothclial ystn (RES) nd therelorehir i.travascularhalfljle is slrort l 3 hours)GelatiDsflcctcoagulatjonia alteratjonsn plateler ctnily,althouEh his effecih clinically nsiEnilicanrSevere naphy.lactoid cactions ccur nore onen {irh urea inkedsolLrlions0/20001 onparedwirh succinylatdrepararioDsl/13000peryear). elatins o not causc cnaldysfutrction.Non.pblein,ynrheticolloids lHydroxle$yldtedrarahlHESr' . b dr fhed. . - l polyma f

P!asma xpande6arc used to re5tore he clrcuLatingoLume f ahypovoLaemkalient. yp ally, olloidsareused o expandhe plasmavoLume, Lthoughombinations f hypenoni.crystaLLoidnd .ollodhave c.entLy eenused.The curcntLy valable oLLoldsary n thenphysko hemi.aL,harmacoynam.and harma.o lneli.prcperlies.npa iruLai,heydlfier n molecular eight,whi.hpartlydelem nes hetrduralion f actlon,and n their ab Lty to expand he plasma olume.De o1 ,hrd 'o / ,e+y ' rd . ! a d \ ,pe ' ro ' o 'od ro f ro . . ' nporeoxysen Llr wthin lhe mi.rocirculaUon.espilehe benefits,he useoi dextran nd hish mole.ular eighl larchess lim ed by theirnegatve mpact n coagulauon, addluon,hesemacro ole(ulesmayaLsondu.eacuterenaai!orei soscept lepatents.Curcntresearchocuseson the dcvcLopnenlr anilicaLoxygen.carrlccs plasma xpandeu.These ubstan.es,hich ndudemod iedsiromal.freeaemog binandperfluoro.arbonmuLsns ,areundeong din.altfiaLs,(elrwords aLbumin;.olloid;extran; ydroxyethyltarch; elatin

RobM.Cohon,fi.hB,FRa,s Spe.iolis( egist@rn Anaesthesia( theQueensMediealcentrc, otinshan.Hequalifredfian tlanches.lUnive6ity befote tainins in swansea, UKand GaslordNsV Austtatia.His nterestsn.lude cgional noesthesiondpott gtaduote edi.ol

lohnothon otunon,8a,D4, sAssociate tufessot nd Readerin Anoetthesio t he UnivetsityfNoftinqhanondon Hananrycansultant naesthetistt theQueensledicolcentrc,Nattinqhan.His ntetestsncludeisk nanagenent, iaethics,cqianal naesthesraandpathaph'/siolagkalnadelling.e s honatary ectetory ftheAhaestheti. esearcha.ieq and a nenbet alsetetol edi(a l

aDylopectjn. arurally ccurinS tarchesre apjdly ydrolysediruiro by amylase, nd hreiorele IIESdolecules restabi.liz.d by substitutinSydroxyethylgroupsor hydroxyl roups llhe C:, Cr andC6 ositionsf theglucoseesjdusHES s available s l, 6 and 1070solutions,vith varyingMww: owmolecular ei8ht70kDal,mediunmolecnlarreiShl[130270kDa)and rj8hnole.ularweigr! (llMw; > 450kDr.MolarsubstilutioDMSl s th. ratiool substjturedydroxyethylEroupsnd the oralmmber ol glucosc niis (loivMS,0.4 0 5;hi8hMS,0.620 70) Hydroxyelhyl.esiduest C: veryelfeclivelyhinder ydrolysis hi8hC):C6.ariond a hi8hMSbothprolonEthedural ionfact ioDf HES

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Propertlesnd e.ommnddosege f available lasma xpanderslnt6Ecubr voun. .fiedr!, (hooB) (houB)

Albumln .5% P@ieln6% Herastarch450,0.7) Ahylopectln dedvatave

(200&.r)6% etstdch (130/0.4) AmyLope.llnenvaive

2@70@

1'23,224.t

t9

(6%)3 nl/lt(10%) 0 murg

1.5 /kg1.581kg

tlES, ydbry.thyl at.d tarchiMW^,uEbe.tv.trged mole.0lartrlghi MW- welsht!v.69dndL*ularwelshtrTf, hiFLlls

HES 00

HEShar a warerbindinE capacityof 20-30ml/8. After hydro-lysis by amylase, he rcsultinS f.atments of HEs are excretedrenallywithin 24 hou6 of infusion-A smau racton or starchentersheRES.nd he nterstilium,HESatrenuatscapillary eaka8e uing the inflammaloryresponse nd restores acrophaSeunclionaftermajorhaem-orrhag. ddiionally, tar.hesmprovemicroci.culatoryxygenfluxby rcducinE loodviscosity. hh benefilhasbendemon-stratedn fte sDlanchoicirculadon.!

130

l0'J5200

6.5

tt-411

HighMs stdh impaiG coaSulatonby reducnE te concnira-tion of factor {ll: vltlc andvon willeb.dd factor(vWF).Platelelacriviry is also hamperedby block.de of the platelet fibrinoSenreceplorSlycoprcteh llb-lll} smaller moleculesof siarch andrhosewith lessMs produce gligible coa8iiadon defe.ts.r HMwHESand highMSpolynG ale nore likely lo cause enal mpair-mentdue o renal ubular lockaSey hypeNiscousrine.LowMS stdch causes latent, ole-dependentt h typically f theupper 6o due o tissue equstralion.ecausef these ffects,

Comparisonfvolume-expandlngfficayndduBtionof actlon fplasraaxpanders

E a3 eI E;EEE5:

Coluni wldth llr{Er6 apprornde teLrlv. dqErionormrLme.up.nsion effed3. HEs,hydrcxyelhylated rlr.h

oMEb4L'od,^[dt l i .e' .d'

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llES is limired o 1.502.5 lifics/day.Th. incidence l severeanaplrylactoidesctjonss ess haD /16000Dexrrans .epolysacchnridesroduced y the bacte um l,eu.onoito. meienle.oidesctin8on sucrose. cid hydrolysis ndsubsequenrthanol ractionation roducenle {iral producrs:dextran 0 (Mw,, : 40 kDal nd dextraD 0(Mw" : 70 kD3J.I e \ l d , r 0 . - d / 0 o r r o 0 _ l I d ) 0 2 . r l u f s d d - 8 . - ep qtively. -he idneysapidlyelidinat 0%oldeitan40 and50%of dexran70 urchanged, lrjlsr he remainders netabolizedro Slucose. snall ropor(ionof dextran .ters he nrerstitiunor is elidinatd ia thegut.The nrravascularali ife s detrminedby particlc izc,wnh dcxrran 0 cnaining or 6 8 houFconpafcdwith 5 hou$ Ior dextfan 0.Dextranproduces inilnr nicrocirculrrory fiecls o llES.lschaenin{epe.lusiodnjury is arlenua(edy a reductio.oiacrivaredeucocyr .dothlial lleraction.Dexlran 0 and dexran70 solutio^s avesinilar ellects ncoaEulariono HES,which inirs rhen use o 1.58/k8/day In.dditio., dextran ronotes ib nolysis. cure enal npairnentcaused y renal ubularobstrudionhas beenassociat.d nhdextan,particularlyr hyporolacDia, liguriaor paticntswilhexislilSrenal dysluction. Thc nridcncc ol scvcrcanaphylacloid eactionss 1/4500 crycar.Hypertonic aline olutions apidlymobilizc xrravrsculrrluidI no ' \ n ' ' 1 . . . o n b y . r . J p - r ' o n l . r yh e Do n . J . . r p p . o r . -matcly lold hatoI plasnaThismechinlsnhasbeen uEgesledlo reducenlrac.nnjalolume ndpressuren svere ad njuryIn isolation, ypenonjc olutions xhibitposilive ardiovasculareifecrs uchasposi(iveno|rolyandvasodilstion tlc systemicandpulmonaryncularions.l l ) p e , . i c . / r a r l o i d . p , o d uo i y " b r . l p d r n d p d n l o r 'andso heyarenixed wirh a colloid e.9. 2% Nacl + 6% HES200or 7,5%NaCl+ 6% dexta.70) o prolongheir urar ion

ol acrion.An infusionof 4 n1/kE n severe ypovolaeniae.E.traura, burns) s.econmended.Artlficlal orygei carlersPlasnaexpandelso nol lranspon xy8enHiemoglobin-basedoxygen ariets consisr i sr.onalhee haeooSlobinhat acks2, 3 diphosphoSlycerarend has a very high oxygenafiiniry,Modrhcarionl lhese xygen anjeNby polynedzarion,tabilizadon, onjugaiion,ybridizationrrcaps!lalion asovercomelhese roblns. edluorocafbonxySen a(iersconsisl f nen,orSanic ole.ules hardissolvearSe olumes f 8as Unfo(uDately,heyhavea ljnear xy8en indnrg apa.iry nda narowlherapeuricndex hatcan cad o oxygcn oxicity.Haenoglobinbased xygercarieF and perfhorocarbonxy8cn arncrs reundefEo inEl in .a l r ia l \ .

1 Unfer , Bellomo ,Soyce , el al. A.omparison f aLbumrnndsallne or Ruid esu(tation n the ntensiveare un . E 4//l,led

2 R too D, Gosling , Bonni. C,et aL.5planchni.xygenationnpauenE ideoingabdomlnalaoftk neurysmepa andvoLumeexpansioiwth eLoHAES.drdbrascular es 0a2t ot 12a 33.

3 faGchc, BoLdt, rebsc, et al. he influence f nthvascuLar.o -ae r5edp/ ^ i r5q 1e4 rd 'o ,e r ! , "a ' (Lp ep! r 'o '1 6 0 0 l L S0 0 . - o . . o o g r l a r i o p a r h ' 1 ' ' d e g og 1 . ' o 'abdomlnaLsuBery.re5th,4rrlq 2a011 2: 565 71.

Roberts AL!e6onP, SdnnF,et al. coLLolde6us rystalLoldsor nuidresu*itarionn diti.aLLyl parlenrs.a.htaneDatdbate ystRev

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