EVIDENCES OF COLLOID

Eka Seprianti Widiastuti

Anesthesiologist Intensivist
Siloam Hospitals Balikpapan

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 OUTLINE

• What Is Colloid?
• Natural Colloid
• Synthetic Colloid
• Which Fluid?
• Take Home Message

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What is colloid?

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 Characteristics
• High MW substance that largely remains in
intravascular compartment  generating
oncotic pressure
• Considered to have greater intravascular
persistence (compared to crystalloid)  LOST
when capilar permeability significantly
changes (severe trauma, sepsis)

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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Natural Colloid

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 Albumin
• Comprising 50-60% of all plasma proteins
• Synthesized only in liver
• Half life ± 20 days
• 5% solution (iso-oncotic)  80% volume
expansion
• 25% solution  200-400% volume expansion

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 Albumin
• Used :
 fluid resuscitation
 treatment due to loss of plasma
 Hypoalbuminemia
 ECAD

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 Albumin
• Advantages :
 lesser side effects
 greater degree of volume expansion
 binding protein
 normal anion gap (negatively charge protein)
• Disadvantages :
 (relatively) expensive
 volume overload
Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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Synthetic Colloid

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 Dextran
• Highly branched polysaccharide molecules
• Synthesized using bacterial enzyme dextran sucrase
from Leuconostoc mesenteroids
• Solutions : 6% (70), 10% (40)
• Excreted via kidney (primarily)
• Used :
 microsurgical reimplantation
 extracorporeal circulation (during CPB)

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 Dextran
• Advantages :
 Volume expansion (100-150%)
 Improve microcirculatory flow  hemodilution,
inhibiting erythrocytic aggregation
• Disadvantages :
 Anaphylactic reaction (reactive antibody)
 Coagulopathy
 Interference with cross-match
 Precipitation of AKI
Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 HES
• Derivatives of amylopectin  highly branched
compound of starch
• Solution : 6% (iso-oncotic), 10% (145% volume
expansion)
• Advantage : cheaper
• Disadvantages : anaphylactic reaction, accumulation,
increase in amylase level, coagulopathy, kidney
impairment,

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 HES
• Advantages :
 Cost effective
 Maximal allowable volume  >dextran
• Disadvantages :
 Anaphylactic reaction (reactive antibody)
 Coagulopathy
 Accumulation
 Precipitation of AKI

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 Gelatin
• Large protein molecules, formed from
hydrolisis of collagen
• Produced by thermal degradation of cattle
bones
• Leads to 70-80% volume expansion

Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 Gelatin
• Advantages :
 Cost effective
 No limit of transfusion
 No effect of kidney impairment
• Disadvantages :
 Anaphylactic reaction
 Effect on coagulation
 Circulatory disturbance  increase plasma RAA
activity
Mitra S, Khandelwal P: Are all colloid same? How to select the right colloid?. Indian J Anaesth 53(5):595, 2009.
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 Characteristics of Colloids

Evidence-based colloid used in critically ill: American Thoracic Society Consesnsus Statement Am J Respir Crit
Care Med 170:1247-1259,
16 2004.
Which Fluids?

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VISEP Study

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VISEP Study

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6S Trial

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CHEST Trial

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CHEST Trial

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 CHRYSTMAS Study
Voluven Normal Saline
(N=100) (N=96)

Volume (mL) required to 1379 1709

achieve HDS
Time to achieve HDS (h) 11.8 14.3

SARs (serious adverse 53 44

reactions)
SARs leading to death 38 32

Doubling of SCr (number of 8 11

subjects)
Required RRT
Number of subjects 21 11
Duration of RRT (days) 9.1 4.3
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2013 HES SUSPENDED

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SSC 2016

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SAFE Study

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ALBIOS Trial, 2014

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SSC 2016

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 Albumin can ameliorate
the disturbed microcirculatory effect of sepsis
• Albumin decreases neutrophil activation induced by fluid infusion,
crystalloinds and synthetic colloids increase it. Rhee P, et al. Crit Care Med
2000; 28(1): 74-78.

• Albumin reduces TNF induced endothelial activation. Nohe et al Intensive

Care Med 1999; 25: 1381-1385; Zhang et al Cardiovasc Res. 2002
Sep;55(4):820-9

• Albumin solution reverses the LPS induced albumin leakage across vessel
walls. Powers KA, et al. Crit Care Med 2003; 31: 2355-63 ;Anning PB et
Intensive Care Med. 2004 Oct;30(10):1944-9

• Albumin infusion results in sustained thiol levels in septic patients. Quinlan G,

et al. Clin Sci 1998; 95: 459-65. 29
Impairing Factors in Sepsis

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 Fluid Therapy in Septic Patient
Albumin is retained intravascularly… …and expands plasma volume

SAFE investigators Int Care Med 2011, 37 Ernest et al Critical Care Medicine:Volume
(1), 86-96 27(1)January 1999 pp 46-50

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 Take Home Message
• Fluid in sepsis and ICU
 Never use HES
 Consider albumin in very sick patient
• Fluid perioperative setting (and trauma)
 HES still could have their place (very
limited)
 More emphasis in fluid strategy than the
fluid itself
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Thank You
dr_echa@yahoo.com
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