Colloids versus crystalloids for fluid resuscitation in critically ill patients.
BACKGROUND
Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.


OBJECTIVE
To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.


METHODS
We searched the Cochrane Injuries Group Specialised Register (searched 16 March 2012), Cochrane Central Register of Controlled Trials 2011, issue 3 (The Cochrane Library), MEDLINE (Ovid) 1946 to March 2012, Embase (Ovid) 1980 to March 2012, ISI Web of Science: Science Citation Index Expanded (1970 to March 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to March 2012), PubMed (searched 16 March 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles.


METHODS
Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates.


METHODS
Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.


RESULTS
We identified 74 eligible trials; 66 of these presented mortality data.Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 21 trials compared hydroxyethyl starch with crystalloids, n = 1385 patients. The pooled RR was 1.10 (95% CI 0.91 to 1.32). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloid Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR was 0.91 (95% CI 0.71 to 1.06).


CONCLUSIONS
There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK. pablo.perel@Lshtm.ac.uk
Pablo
P
Perel
Ian
I
Roberts
D000418:Albumins / Q000627:therapeutic use; D001798:Blood Proteins / Q000627:therapeutic use; D003102:Colloids / Q000627:therapeutic use*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D000077324:Crystalloid Solutions; D003911:Dextrans / Q000627:therapeutic use; D005440:Fluid Therapy / Q000379:methods; D005780:Gelatin / Q000627:therapeutic use; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000627:therapeutic use; D007552:Isotonic Solutions / Q000627:therapeutic use*; D010952:Plasma Substitutes / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D015532:Rehydration Solutions / Q000627:therapeutic use; D012151:Resuscitation / Q000379:methods*
D000418:Albumins; D001798:Blood Proteins; D003102:Colloids; D000077324:Crystalloid Solutions; D003911:Dextrans; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D010952:Plasma Substitutes; D015532:Rehydration Solutions; D005780:Gelatin