Are colloids more effective than crystalloids in reducing mortality in people who are critically ill or injured

Perel P, Roberts I

Published Online:

March 16, 2011

Trauma, burns or surgery can cause people to lose large amounts of blood. Fluid replacement, giving fluids intravenously (into a vein) to replace lost blood, is used to try to maintain blood pressure and reduce the risk of dying. Blood products, non-blood products or combinations are used, including colloid or crystalloid solutions. Colloids are increasingly used but they are more expensive than crystalloids. The review of trials found no evidence that colloids reduce the risk of dying compared with crystalloids.

Abstract (click to read)

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.

Objectives:

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

Search strategy:

We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S), and The Controlled Trials metaRegister (www.controlled-trials.com). Reference lists of relevant studies and review articles were searched for further trials. The searches were last updated in September 2008.

Selection criteria:

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.

Data collection and analysis:

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.

Main results:

We identified 65 eligible trials; 56 of these presented mortality data.

Colloids compared to crystalloids

Albumin or plasma protein fraction - 23 trials reported data on mortality, including a total of 7754 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (95% CI) 0.92 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.91 to 1.09). Hydroxyethyl starch - 17 trials compared hydroxyethyl starch with crystalloids, n = 1172 patients. The pooled RR was 1.18 (95% CI 0.96 to 1.44). 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

Eight trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05).

Authors' 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.

This record should be cited as:

Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD000567. DOI: 10.1002/14651858.CD000567.pub4

Assessed as up to date:

September 30, 2008

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Primary Review Group:

Injuries Group

Health topics:

Orthopaedics & trauma > Emergency medicine > Emergency medicine

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Are colloids more effective than crystalloids in reducing mortality in people who are critically ill or injured

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