colloids vs crystalloids

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Nick8

Nick8

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Do you prefer use colloids or crystalloids when patient has a hemorragic shock?
What kind of colloids do you use?
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Nick8 said:
Do you prefer use colloids or crystalloids when patient has a hemorragic shock?
What kind of colloids do you use?
Click to expand...

After reading your last 2 posts, I feel like you are opening a critical care textbook from the mid-1990's and just asking random questions from it.
 
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Nick8 said:
SLUser11,

Why do you think so? Do you really know what's the better for liquid resuscitation? I don't know .....and Jl Vincent doesnt know : http://www.ncbi.nlm.nih.gov/pubmed/18284011

another view on this problem: http://www.ncbi.nlm.nih.gov/pubmed/17943746

Apollyon,

thank you! you're right.
Click to expand...

Do you have a real question, or are you just trolling for someone to debate with?


The only situation where colloids are useful for resuscitation is where they are equal in price or cheaper than crystalloids, while simultaneously being equally or more available. This is possibly the case in Moscow as it is in Australia....but not in the US.

Colloids are safe, as proven in the SAFE trial, but they are not cost effective.

If you really just want to know what we do in the US, we don't use colloids for hemorrhagic shock. Some of the medicine docs I've met like to give 3% albumin to critically ill patients with hypoalbuminemia, but I prefer to do an elaborate dance and shake chicken bones over the patient.
 
SLUser11,
Thank you for your answer. As I know there was a comparison between 4%albumin and NS in patients in ICU for fluid resuscitation. http://www.nejm.org/doi/full/10.1056/NEJMoa040232
But what about Hydroxyethyl starch (HES) solutions? (Thay're cheaper) Do you use them in any case?

sevo8528,
Why blood??? I think that's more important to recover the volume of blood, but not the number of erythrocytes? (Paul L. Marino.The ICU book,third edition. Chapter#36)
 
SLUser11 said:
Do you have a real question, or are you just trolling for someone to debate with?


The only situation where colloids are useful for resuscitation is where they are equal in price or cheaper than crystalloids, while simultaneously being equally or more available. This is possibly the case in Moscow as it is in Australia....but not in the US.

Colloids are safe, as proven in the SAFE trial, but they are not cost effective.

If you really just want to know what we do in the US, we don't use colloids for hemorrhagic shock. Some of the medicine docs I've met like to give 3% albumin to critically ill patients with hypoalbuminemia, but I prefer to do an elaborate dance and shake chicken bones over the patient.
Click to expand...

no need to be all that harsh on someone who's not from the States.
Considering the question, l'm from Europe and we also tend to replace blood with blood, which makes sense, as soon as possible. By only replacing crystalloids or colloids you still lack the erythrocytes, and therefore no oxygen carrying capacity which would be major step back in a long term.
 
Intensivist said:
no need to be all that harsh on someone who's not from the States.
Considering the question, l'm from Europe and we also tend to replace blood with blood, which makes sense, as soon as possible. By only replacing crystalloids or colloids you still lack the erythrocytes, and therefore no oxygen carrying capacity which would be major step back in a long term.
Click to expand...

Maybe I was being too harsh. I just felt like the tone of the post was trollish, and the OP had more of an agenda than a true question. I didn't notice he was from Moscow until after my first response.
 
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Apollyon said:
Well, the kid's in Russia. I'm thinking it's more a comparison thing/not aware of how things go in the West.
Click to expand...

cocolovehu said:
Well, the kid's in Russia. I'm thinking it's more a comparison thing/not aware of how things go in the West.
Click to expand...

Cool! Troll plagiarizes me! Since he didn't quote it, but posted it as his own...wow, I'm honored! However, he did it to one other person, too.

See ya; wouldn't want to be ya! Asta lasagna, don't get any on ya!
 
Apollyon said:
Cool! Troll plagiarizes me! Since he didn't quote it, but posted it as his own...wow, I'm honored! However, he did it to one other person, too.

See ya; wouldn't want to be ya! Asta lasagna, don't get any on ya!
Click to expand...
Well it's almost certainly a spam bot...what I'm curious about is how it made it past the "Captcha" verification system.
 
I use NS or LR in the setting of acidosis, which would be exacerbated by using NS. Blood for actively hemorrhaging pts. Crystals are much cheaper than colloids. According to SAFE study, colloids are just as safe (or unsafe) as crystals. Except in the trauma population, where colloids were associated with increased risks/mortality. Using a warmer is key - something we often forget in a high intensity situation. You want to keep from developing the "terrible triad": hypothermia, acidosis and coagulopathy. A "problem" with giving LR is that you often have to give blood and they are not considered compatible, though many say this is more a theoretical than an actual concern.

I'm conservative with blood, and I feel we all should be. Blood causes immune suppression, poses an infectious risk and risk for anaphylaxis. In my opinion, some clinicians transfuse way too casually. Take this from someone who works at a busy trauma center/ICU and transfuses multiple times every shift. Pts will look great after your transfusion, but there are longer term risks that the pt walks away with that you'll never have to worry about but they will. As a way of example, there was a big study published a while ago which showed that pts who were transfused in the OR during colon mass resection had significantly higher rates of cancer recurrence.

I do agree that in a passively hemorrhaging pt, consider giving product. The concern about O2 carrying capacity is heard! Maybe give 1 unit in a passively hemorrhaging pt and recheck Hgb, more units if actively hemorrhaging. Always stay ahead and don't forget to give FFP and platelets for multiple PRBC units. Keep your pts warm.
 
Intensivist said:
no need to be all that harsh on someone who's not from the States.
Considering the question, l'm from Europe and we also tend to replace blood with blood, which makes sense, as soon as possible. By only replacing crystalloids or colloids you still lack the erythrocytes, and therefore no oxygen carrying capacity which would be major step back in a long term.
Click to expand...


Wasn't there that famous experiment where they drained a certain amount of blood from pigs and replaced it immediately and the pigs had a high mortality rate anyway? Because of the trans-cellular fluid shift? I think that's the rational for using crystalloid (in a 3:1 ratio) over blood as the main volume expander in trauma.
 
by only using crystalloids you dilute blood, making it profounding the anaemia and therefore make O2 delivery poor. Crystalloids are great, as are colloids and blood products, but only when used wisely.
 
Intensivist said:
by only using crystalloids you dilute blood, making it profounding the anaemia and therefore make O2 delivery poor. Crystalloids are great, as are colloids and blood products, but only when used wisely.
Click to expand...

I don't think anyone would suggest using ONLY crystalloid/colloid and give NO blood. However, the OP's question was: "Do you prefer use colloids or crystalloids when patient has a hemorragic shock?" My interpretation of his question is that he wants to know what we think is the most important fluid for resuscitation in acute hemorrhage.

From 'The ICU Book' by Paul Marino (3rd ed, pages 224, 225, "...the first priority in the bleeding patient is to support cardiac output... ...blood is not the fluid of choice for early volume resuscitation in acute blood loss".

1) the low cardiac output is going to kill them a lot quicker than the anemia, so replacing red blood cells is not a priority.
2) diluting the viscosity of the patient's blood with crystalloid has the effect of decreasing the after-load on the heart, thus promoting cardiac output (which may keep them alive).

Therefore, my conclusion is that blood and other products are important, but not the first priority in resuscitation (although you can start both at the same time, keep in mind what your resuscitative goals are). A little anemia can be a good thing.

In terms of whether crystalloid or colloid, I don't think there is any good evidence of superiority either way. Having rotated through a bunch of hospitals, I have never seen colloid used as a primary resuscitative fluid in hemorrghagic shock. Sometimes used albumin solutions in hypoalbulinemic patients, but thats about it. Mostly due to the concerns listed above (cost, availability, rare but present anaphylaxis) and no apparent benefit in most situations.

Sidenote on hydroxyethyl starch to Nick: supposedly they inhibit platelet aggregation, which I imagine is not desirable in someone you are treating for, well, bleeding.
 
good points there, but l wasn't referring to first stage of fluid resuscitation for acute haemorrhage, but rather and common ICU scenarios with patients with ongoing bleeding for several hours. most here will agree unless there is real need for massive transfusion protocols early on, non- blood products are fluids of choice for initial resuscitation. But then again, you have to combine in patients with real massive bleeds b/c sole crystalloid/colloid resus will do lil' to nothing for these kind of patients (1:1:1 ratio).
 
Intensivist said:
good points there, but l wasn't referring to first stage of fluid resuscitation for acute haemorrhage, but rather and common ICU scenarios with patients with ongoing bleeding for several hours. most here will agree unless there is real need for massive transfusion protocols early on, non- blood products are fluids of choice for initial resuscitation. But then again, you have to combine in patients with real massive bleeds b/c sole crystalloid/colloid resus will do lil' to nothing for these kind of patients (1:1:1 ratio).
Click to expand...

This is an excellent point. I think some residents, especially in surgery, begin to view transfusions as universally evil, and will let someone bleed down to very low levels before pulling the trigger on some PRBCs.

There's no doubt that restrictive transfusion policies are better, and there appears to be a linear relationship between number of units PRBCs tranfused and morbidity/mortality. However, when there's a bleeding patient who remains unstable after initial crystalloid resuscitation, they need blood.

When it comes to more stable, or at least not actively crashing ICU patients, I think transfusion is a touchy topic, and depends heavily on the doctor's definition of "asymptomatic" anemia.
 
I really wish my surgery residents would stop giving people hespan. Really.

I mean to abide by the data and only give crystalloid since it's cheaper, but I admit to sometimes trying to 'replete the albumin'. Sigh.

But, c'mon, hespan? Why?
 
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