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June 23, 2014 by dailybolusoflr

Medical Minute from Darren Mareiniss, MD JD

Colloid versus Crystalloid for Hypovolemic Shock – The CRISTAL Randomized Trial

Multicenter randomized clinical trial – 2857 ICU patients treated for hypovolemic shock (sepsis, trauma or other) in 57 ICUs in Belgium, France, North Africa and Canada
Inclusion Criteria:  No prior fluid bolus resuscitation for hypovolemia.  Hypovolemic shock was defined as – (1) SBP < 90, MAP < 60, orthostatic hypotension or a delta pulse pressure of 13% or higher; (2) evidence of low cardiac filling pressures or CI by invasive or non-invasive monitor; and (3) signs of hypoperfusion with 2 of the following: GCS < 12, U/O 3 seconds, Lactate > 2, BUN > 56 or FeNa < 1%. 
Exclusion: Burn, advanced liver disease, coagulation disorder, pregnant, allergy, CRF
Intervention:1414 received boluses with Colloid (gelatins, dextrans, hydroxyethyl starch or albumin) at the discretion of the treating physicians.  1443 patients received boluses with crystalloid (LR, NS or hypertonic saline).  All patients had crystalloid as maintenance fluid. 
Results:
1. Primary outcome – no difference in 28 day mortality – 359 deaths (25.4%) in colloid group vs 390 (27%) in the crystalloid group – RR .96( (95% CI, .88-1.04) P=.26). 
2. Secondary Outcomes – At 90 days, there were significantly more deaths in the crystalloid group.  There were 434 deaths (30.7%) in the colloid group vs 493 (34.2%) in the crystalloid group – RR . 92 (95% CI, .86-.99; P=.03).   Also, there were significantly more days alive without mechanical ventilation in the first week in the colloid group vs the crystalloid group – mean days 2.1 vs 1.8 days – RR .3 (95% CI, .09 – .48, P=.01).  There was also significantly more days alive and without vasopressors in the first week in the colloid group.  The difference in mean days was 5 vs 4.7 – RR .3 (95% CI, -.03 – .5).  There was also significantly more volume of bolus fluids in the first 7 days in the crystalloid group.  Also, there was no difference in the total amount of blood products transfused in the colloid vs crystalloid group.  There was no difference in renal replacement therapy (dialysis) between the two groups. 
Conclusions:
·         There is no difference in 28 day mortality when comparing bolus administration of crystalloid vs colloid in hypovolemic shock.
·         There was more fluid volume administered in the crystalloid group than the colloid group.
·         There appeared to be a potential 90 day mortality benefit in the colloid group that needs to be further studied.
·         There was potential ventilator free day benefit and decreased duration of vasopressor therapy with colloid.  Again, no conclusion can be made, but further study is warranted.
·         There was no difference in dialysis or blood transfusions between the two groups

Bottom line – There was no difference in 28 day mortality between the two groups.  However, some the secondary findings suggest potential benefit with colloid resuscitation.  There was significantly decreased 90 day mortality in the colloid group.  In addition, there was a statistically significant decreased duration of vasopressor use and ventilator support in the colloid group during the first week. These secondary findings need to be further investigated. 
Interesting note– In the colloid group, 70% of patients were resuscitated with hydroxyethyl starch.  Prior studies have shown that use of this fluid increases the incidence of acute kidney injury and need for dialysis.  However, this was not seen here.  Is it possible that an overall benefit of colloid resuscitation may have negated the detrimental effects of this fluid?
References:
Annane D, Siami S, Jaber S et al.  Effects of Fluid Resuscitation with Colloid vs Crystalloid on Mortality in Critically Ill Patients Presenting with Hypovolemic Shock.  JAMA. 2013:310(17):1809-1817.

Myburgh JA, Finfer S, Bellomo R et al; CHEST Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367(20):1901-1911.  

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