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.
OBJECTIVE
To assess shock reversal and required fluid volumes in patients with septic shock.


METHODS
Prospective before and after study comparing three different treatment periods.


METHODS
Fifty-bed single-center surgical intensive care unit.


METHODS
Consecutive patients with severe sepsis.


METHODS
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.


RESULTS
Main outcome was time to shock reversal (serum lactate <2.2 mmol/L and discontinuation of vasopressor use). Hemodynamic goals were mean arterial pressure >70 mm Hg; ScvO2 <70%; central venous pressure >8 mm Hg. Safety outcomes were acute kidney injury defined by Risk, Injury, Failure, Loss, and End-stage kidney disease criteria and new need for renal replacement therapy. Hemodynamic measures, serum lactate, and creatinine were comparable at baseline in all study periods (hydroxyethyl starch n = 360, gelatin n = 352, only crystalloids n = 334). Severity scores, hospital length of stay, and intensive care unit or hospital mortality did not differ significantly among groups. All groups showed similar time to shock reversal. More fluid was needed over the first 4 days in the crystalloid group (fluid ratios 1.4:1 [crystalloids to hydroxyethyl starch] and 1.1:1 [crystalloids to gelatin]). After day 5, fluid balance was more negative in the crystalloid group. Hydroxyethyl starch and gelatin were independent risk factors for acute kidney injury (odds ratio, 95% confidence interval 2.55, 1.76-3.69 and 1.85, 1.31-2.62, respectively). Patients receiving synthetic colloids received significantly more allogeneic blood products.


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.
Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University Jena, Jena, Germany.
Ole
O
Bayer
Konrad
K
Reinhart
Matthias
M
Kohl
Björn
B
Kabisch
John
J
Marshall
Yasser
Y
Sakr
Michael
M
Bauer
Christiane
C
Hartog
Daniel
D
Schwarzkopf
Niels
N
Riedemann
D000368:Aged; D015331:Cohort Studies; D003102:Colloids / Q000627:therapeutic use; D003422:Critical Care / Q000379:methods; D000077324:Crystalloid Solutions; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D005500:Follow-Up Studies; D005780:Gelatin / Q000627:therapeutic use*; D006439:Hemodynamics / Q000502:physiology; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000627:therapeutic use*; D007362:Intensive Care Units; D007552:Isotonic Solutions / Q000627:therapeutic use; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D018570:Risk Assessment; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016019:Survival Analysis; D016896:Treatment Outcome; D014883:Water-Electrolyte Imbalance / Q000517:prevention & control
D003102:Colloids; D000077324:Crystalloid Solutions; C485123:HES 130-0.4; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D005780:Gelatin