November 6, 2013

Making a Pragmatic Choice for Fluid Resuscitation in Critically Ill Patients

Author Affiliations
  • 1Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Dr Angus is Associate Editor, JAMA.

Copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2013;310(17):1803-1804. doi:10.1001/jama.2013.280503

One of the oldest debates in medicine is whether patients with hypovolemic shock should be resuscitated with colloids (eg, albumin or hydroxyethyl starch [HES]) or crystalloids (eg, normal saline or Ringer lactate). Despite thousands of patients enrolled in trials of alternative fluid strategies, consensus remains elusive and practice is widely variable.1,2 The argument for colloids is that, because they rely on oncotic pressure gradients created by their suspension of large molecular weight protein or starch, they selectively expand the intravascular space.3 In contrast, crystalloids, which rely on the osmotic gradients of their solutes, equilibrate more rapidly across intra- and extravascular spaces. Thus, to achieve similar restoration of blood volume, more volume of crystalloid may be necessary, with unwanted excess edema.4 However, shock states, such as sepsis, induce endothelial leaking with extravasation of protein and other large molecules,5 which undermines the theoretical advantage of colloids. Furthermore, colloids are considerably more expensive; human-derived colloids, such as albumin, carry theoretical risks of infection; and the large molecule proteins and starches may have unwanted immunogenic effects.4 Some starches also appear to cause renal injury.6

First Page Preview View Large
First page PDF preview
First page PDF preview