Colloids versus crystalloids for fluid resuscitation in critically ill patients

Disasters, children and the kidneys

Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters.

Acute Kidney Injury in Active Wars and Other Man-Made Disasters

Acute kidney injury (AKI) is frequent during wars and other man-made disasters, and contributes significantly to the overall death toll. War-related AKI may develop as a result of polytrauma, traumatic bleeding and hypovolemia, chemical and airborne toxin exposure, and crush syndrome. Thus, prerenal, intrinsic renal, or postrenal AKI may develop at the battlefield, in field hospitals, or tertiary care centers, resulting not only from traumatic, but also nontraumatic, etiologies. The prognosis usually is unfavorable because of systemic and polytrauma-related complications and suboptimal therapeutic interventions. Measures for decreasing the risk of AKI include making preparations for foreseeable disasters, and early management of polytrauma-related complications, hypovolemia, and other pathogenetic mechanisms. Transporting casualties initially to field hospitals, and afterward to higher-level health care facilities at the earliest convenience, is critical. Other man-made disasters also may cause AKI; however, the number of patients is mostly lower and treatment possibilities are broader than in war. If there is no alternative other than prolonged field care, the medical community must be prepared to offer health care and even perform dialysis in austere conditions, which in that case, is the only option to decrease the death toll resulting from AKI.

Malaria: What's New in the Management of Malaria?

The global burden of malaria remains high, with 216 million cases causing 445,000 deaths in 2016 despite first-line treatment with artemisinin-based combination therapy. Decreasing transmission in Africa shifts the risk for severe malaria to older age groups as premunition wanes. Prompt diagnosis and treatment with intravenous artesunate in addition to appropriate supportive management are critical to reduce deaths from severe malaria. Effective individual management is challenging in settings with limited resources for higher-level care. Adjunctive therapies targeting the underlying pathophysiological pathways have the potential to reduce mortality. Resistance to artemisinin derivatives and their partner drugs threaten malaria management and control.

Starch Wars-New Episodes of the Saga. Changes in Regulations on Hydroxyethyl Starch in the European Union

After a safety review of hydroxyethyl starch (HES) solutions in 2013, restrictions on the use of HES were introduced in the European Union (EU) to reduce the risk of kidney injury and death in certain patient populations. Similar restrictions were introduced by the Food and Drug Administration in the United States and other countries. In October 2017, a second safety review of HES solutions was triggered by the European pharmacovigilance authorities based on a request by the Swedish Medical Products Agency to completely suspend HES. After several meetings and repeated evaluations, the recommendation to ban HES was ultimately not endorsed by the responsible committee; however, there was a vote for more restricted access to the drug and rigorous monitoring of policy adherence. This review delineates developments in the European pharmacovigilance risk assessment of HES solutions between 2013 and 2018. In addition, the divergent experts' opinions and the controversy surrounding this official assessment are described. As the new decisions might influence the availability of HES products for veterinary patients, potential alternatives to HES solutions, such as albumin solutions and gelatin, are briefly discussed.

Effect of high- versus low-volume saline administration on acute kidney injury after cardiac surgery

Background

Fluid resuscitation is critical to perioperative maintenance of adequate preload and cardiac output after cardiac surgery. Liberal use of saline, however, is reportedly associated with an increased risk of acute kidney injury (AKI) in critically ill patients. This study examined the effects of high- versus low-volume saline administration on AKI after cardiac surgery.

Methods

In this retrospective study, we evaluated 1,740 consecutive patients who underwent cardiac surgery over a 2-year period. The patients were divided into high-volume saline (n=328, 18.8%) and low-volume saline (n=1,412, 81.2%) groups based on the amount of saline (>1 or ≤1 L, respectively) administered during the first 48 postoperative hours.

Results

AKI, the primary outcome, was defined according to the Risk, Injury, Failure, Loss, End Stage classification. There were no significant differences in the incidence of AKI (P=0.46), new renal replacement therapy (RRT) (P=0.39), and early mortality (P=0.52) between the 2 groups. Adjustment of baseline characteristics using propensity score matching showed that high-volume of saline administration was not significantly associated with an increased risk of AKI (OR, 1.22; 95% CI, 0.77-1.93; P=0.38), new RRT (OR, 1.25; 95% CI, 0.68-2.28; P=0.45), or early mortality (HR, 0.98; 95% CI, 0.48-2.02; P=0.97). These results were validated by further adjustments for significant covariates.

Conclusions

High-volume administration of saline in the period following cardiac surgery was not associated with a significant increase in the risk of AKI.

Ringer's lactate solution enhances the inflammatory response during fluid resuscitation of experimentally induced haemorrhagic shock in rats

INTRODUCTION

Hemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in systemic inflammatory response syndrome (SIRS), a recognised cause of late mortality in this case. The aim of this study was to analyse the impact of fluid resuscitation, using two Ringer solutions, on the microcirculation changes that take place during experimentally induced haemorrhagic shock.

MATERIAL AND METHODS

A model of the rat cremaster muscle was used to assess microcirculation in vivo. The experimental groups (n = 10 each) included: control (CTRL); shock (HSG); Ringer's acetate (RAG); and Ringer's lactate (RLG). Microhaemodynamic parameters were measured during the experiment.

RESULTS

A statistically significantly higher level of leukocytes, both those attached to the endothelium and those located in the extravascular space (p < 0.05), was reported in the lactate Ringer (LR) group compared with the AR group. There were significant differences in the activity of A3 arterioles compared with A1 and A2 arterioles. Ringer's lactate solution seemed to the inflammation response during fluid resuscitation from haemorrhagic shock. A3 arterioles are likely to play a role as a pre-capillary sphincter in the skeletal muscle.

CONCLUSIONS

The present study revealed that fluid resuscitation with Ringer's lactate solution exacerbates inflammation in the skeletal muscle. It is worth noting that Ringer's acetate solution reduces local inflammation and could therefore be recommended as the "first line" crystalloid of the fluid resuscitation during haemorrhagic shock.

Intravenous Fluids and Acute Kidney Injury

Over 50% of the human body is comprised of fluids that are distributed in defined compartments. Although compartmentalized, these fluids are dynamically connected. Fluids, electrolytes, and acid-base balance in each compartment are tightly regulated, mostly in an energy-dependent manner to achieve their designed functions. For over a century, our understanding of the microvascular fluid homeostasis has evolved from hypothesized Ernest Starling principle to evidence-based and the revised Starling principle, incorporating the functional endothelial surface layer. The kidney is a highly vascular and encapsulated organ that is exquisitely sensitive to inadequate (insufficient or excess) blood flow. The kidney is particularly sensitive to venous congestion, and studies show that reduced venous return triggers a greater degree of kidney damage than that from lacking arterial flow. Thus, fluid overload can induce severe and sustained kidney injury. In the setting of established acute kidney injury, fluid management can be challenging. Impaired capacity of urine output and urine concentration and dilution should be taken into consideration when designing fluid therapy. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=452702.

Effects of volume resuscitation on the microcirculation in animal models of lipopolysaccharide sepsis: a systematic review

Background

Recent research has identified an increased rate of mortality associated with fluid bolus therapy for severe sepsis and septic shock, but the mechanisms are still not well understood. Fluid resuscitation therapy administered for sepsis and septic shock targets restoration of the macro-circulation, but the pathogenesis of sepsis is complex and includes microcirculatory dysfunction.

Objective

The objective of the study is to systematically review data comparing the effects of different types of fluid resuscitation on the microcirculation in clinically relevant animal models of lipopolysaccharide-induced sepsis.

Methods

A structured search of PubMed/MEDLINE and EMBASE for relevant publications from 1 January 1990 to 31 December 2015 was performed, in accordance with PRISMA guidelines.

Results

The number of published papers on sepsis and the microcirculation has increased steadily over the last 25 years. We identified 11 experimental animal studies comparing the effects of different fluid resuscitation regimens on the microcirculation. Heterogeneity precluded any meta-analysis.

Conclusions

Few animal model studies have been published comparing the microcirculatory effects of different types of fluid resuscitation for sepsis and septic shock. Biologically relevant animal model studies remain necessary to enhance understanding regarding the mechanisms by which fluid resuscitation affects the microcirculation and to facilitate the transfer of basic science discoveries to clinical applications.

Hemodynamic Changes Following Routine Fluid Resuscitation in Patients With Blunt Trauma

Background

The management of trauma patients is often difficult. The American college of surgeons suggests using advanced trauma life support (ATLS) measures. ATLS is regarded as the gold standard for the resuscitation of cases with acute life threatening injuries.

Objectives

To assess the change in base excess (BE) values and central venous pressure (CVP) one and six hours after injection of 1000 cc normal saline in trauma patients admitted to the ICU.

Patients and Methods

According to the inclusion and exclusion criteria, patients were randomly selected to participate in the project. Inclusion criteria included trauma patients admitted to the ICU with a CVP line and who had indication for hydration. In trauma patients, at the zero time period, BP, PR, RR and CVP were measured, and a blood gas test was used to assess Hb, pH, BE, PO₂, HCO₃ and PCO₂. Then 1000 cc of normal saline was injected, and after one and six hours, the same values were re-evaluated.

Results

The mean age of the patients was 38.1 ± 3.9 (range 15 - 60). The mean duration of hospitalization was 7.4 ± 4.4 (range 1 - 21) days. The mean ISS for these patients was 14.33 ± 5.3. BE changes in both groups of patients, based on Hb primary division, showed a significant difference (P ≤ 0.05). The results showed that there was no significant relation between the measured ISS and the changes in base values (P ≥ 0.05).

Conclusions

According to our results, the infusion of one liter normal saline will cause a statistically significant decrease only in BD, after one hour, in patients with moderate to severe ISS. The changes in SBP, PR, CVP and also pH, HCO₃ and Hb were not statistically remarkable.

Albumin resuscitation in burns: a hybrid regime to mitigate fluid creep

Introduction

Globally, many burns units moved away from colloid resuscitation in response to the Cochrane review (1998). Recent literature has introduced the concept of fluid creep: patients receiving volumes far in excess of the upper limit of the Parkland formula. The Cochrane review has been widely criticised, however, and we continued to use 4.5% human albumin solution after 8 h of crystalloid as a hybrid of Parkland and Muir & Barclay's regime.

Methods

Adult patients ⩾15% TBSA were identified from data prospectively entered into our database over a 5-year period (2003-2008). Medical notes and intensive care charts were reviewed comparing volumes of fluids received with requirement estimates. Adverse events were also documented.

Results

A total of 72 cases with 34 sets of intensive care charts were analysed. Mean TBSA was 35.2% (range, 15-95%). A total of 75% survived; 3% were haemofiltered. Forty-one percent of patients were resuscitated using the Parkland formula alone, while 59% switched at 8 h post burn to the Muir and Barclay formula (Hybrid group). There was a significantly greater TBSA in the Hybrid group, but they received significantly less fluid volumes than the Parkland group (P = 0.0363; the Hybrid group received 1.36 times calculated need vs. 1.62 in the Parkland group).

Conclusion

Our patients still demonstrate fluid creep, but to a lesser extent than previously reported. Fluid creep has been mitigated but not eliminated through this strategy.

Preventive nebulization of mucolytic agents and bronchodilating drugs in invasively ventilated intensive care unit patients (NEBULAE): study protocol for a randomized controlled trial

Background

Preventive nebulization of mucolytic agents and bronchodilating drugs is a strategy aimed at the prevention of sputum plugging, and therefore atelectasis and pneumonia, in intubated and ventilated intensive care unit (ICU) patients. The present trial aims to compare a strategy using the preventive nebulization of acetylcysteine and salbutamol with nebulization on indication in intubated and ventilated ICU patients.

Methods/Design

The preventive nebulization of mucolytic agents and bronchodilating drugs in invasively ventilated intensive care unit patients (NEBULAE) trial is a national multicenter open-label, two-armed, randomized controlled non-inferiority trial in the Netherlands. Nine hundred and fifty intubated and ventilated ICU patients with an anticipated duration of invasive ventilation of more than 24 hours will be randomly assigned to receive either a strategy consisting of preventive nebulization of acetylcysteine and salbutamol or a strategy consisting of nebulization of acetylcysteine and/or salbutamol on indication. The primary endpoint is the number of ventilator-free days and surviving on day 28. Secondary endpoints include ICU and hospital length of stay, ICU and hospital mortality, the occurrence of predefined pulmonary complications (acute respiratory distress syndrome, pneumonia, large atelectasis and pneumothorax), and the occurrence of predefined side effects of the intervention. Related healthcare costs will be estimated in a cost-benefit and budget-impact analysis.

Discussion

The NEBULAE trial is the first randomized controlled trial powered to investigate whether preventive nebulization of acetylcysteine and salbutamol shortens the duration of ventilation in critically ill patients.

Trial registration

NCT02159196, registered on 6 June 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0865-0) contains supplementary material, which is available to authorized users.

Postoperative fluid management

Postoperative care units are run by an anesthesiologist or a surgeon, or a team formed of both. Management of postoperative fluid therapy should be done considering both patients’ status and intraoperative events. Types of the fluids, amount of the fluid given and timing of the administration are the main topics that determine the fluid management strategy. The main goal of fluid resuscitation is to provide adequate tissue perfusion without harming the patient. The endothelial glycocalyx dysfunction and fluid shift to extracellular compartment should be considered wisely. Fluid management must be done based on patient’s body fluid status. Patients who are responsive to fluids can benefit from fluid resuscitation, whereas patients who are not fluid responsive are more likely to suffer complications of over-hydration. Therefore, common use of central venous pressure measurement, which is proved to be inefficient to predict fluid responsiveness, should be avoided. Goal directed strategy is the most rational approach to assess the patient and maintain optimum fluid balance. However, accessible and applicable monitoring tools for determining patient’s actual fluid need should be further studied and universalized. The debate around colloids and crystalloids should also be considered with goal directed therapies. Advantages and disadvantages of each solution must be evaluated with the patient’s specific condition.

The impact of Cochrane Systematic Reviews: a mixed method evaluation of outputs from Cochrane Review Groups supported by the UK National Institute for Health Research

BACKGROUND

There has been a growing emphasis on evidence-informed decision-making in health care. Systematic reviews, such as those produced by the Cochrane Collaboration, have been a key component of this movement. The UK National Institute for Health Research (NIHR) Systematic Review Programme currently supports 20 Cochrane Review Groups (CRGs). The aim of this study was to identify the impacts of Cochrane reviews published by NIHR-funded CRGs during the years 2007-2011.

METHODS

We sent questionnaires to CRGs and review authors, interviewed guideline developers and used bibliometrics and documentary review to get an overview of CRG impact and to evaluate the impact of a sample of 60 Cochrane reviews. We used a framework with four categories (knowledge production, research targeting, informing policy development and impact on practice/services).

RESULTS

A total of 1,502 new and updated reviews were produced by the 20 NIHR-funded CRGs between 2007 and 2011. The clearest impacts were on policy with a total of 483 systematic reviews cited in 247 sets of guidance: 62 were international, 175 national (87 from the UK) and 10 local. Review authors and CRGs provided some examples of impact on practice or services, for example, safer use of medication, the identification of new effective drugs or treatments and potential economic benefits through the reduction in the use of unproven or unnecessary procedures. However, such impacts are difficult to objectively document, and the majority of reviewers were unsure if their review had produced specific impacts. Qualitative data suggested that Cochrane reviews often play an instrumental role in informing guidance, although a poor fit with guideline scope or methods, reviews being out of date and a lack of communication between CRGs and guideline developers were barriers to their use.

CONCLUSIONS

Health and economic impacts of research are generally difficult to measure. We found that to be the case with this evaluation. Impacts on knowledge production and clinical guidance were easier to identify and substantiate than those on clinical practice. Questions remain about how we define and measure impact, and more work is needed to develop suitable methods for impact analysis.

Timing and volume of fluid administration for patients with bleeding

BACKGROUND

Treatment of haemorrhagic shock involves maintaining blood pressure and tissue perfusion until bleeding is controlled. Different resuscitation strategies have been used to maintain the blood pressure in trauma patients until bleeding is controlled. However, while maintaining blood pressure may prevent shock, it may worsen bleeding.

OBJECTIVES

To examine the effect on mortality and coagulation times of two intravenous fluid administration strategies in the management of haemorrhagic hypovolaemia, early compared to delayed administration and larger compared to smaller volume of fluid administered.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), ISI Web of Science (SCI-Expanded and CPCI-S) and clinical trials registries. We checked reference lists of identified articles and contacted authors and experts in the field. The most recent search was run on 5 February 2014.

SELECTION CRITERIA

Randomised trials of the timing and volume of intravenous fluid administration in trauma patients with bleeding. Trials in which different types of intravenous fluid were compared were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality.

MAIN RESULTS

Six trials involving a total of 2128 people were included in this review. We did not combine the results quantitatively because the interventions and patient populations were so diverse. Early versus delayed fluid administration Three trials reported mortality and two reported coagulation data.In the first trial (n = 598) the relative risk (RR) for death with early fluid administration was 1.26 (95% confidence interval (CI) 1.00 to 1.58). The weighted mean differences (WMD) for prothrombin time and partial thromboplastin time were 2.7 (95% CI 0.9 to 4.5) and 4.3 (95% CI 1.74 to 6.9) seconds, respectively.In the second trial (n = 50) the RR for death with early blood transfusion was 5.4 (95% CI 0.3 to 107.1). The WMD for partial thromboplastin time was 7.0 (95% CI 6.0 to 8.0) seconds. In the third trial (n = 1309) the RR for death with early fluid administration was 1.06 (95% CI 0.77 to 1.47). Larger versus smaller volume of fluid administration Three trials reported mortality and one reported coagulation data.In the first trial (n = 36) the RR for death with a larger volume of fluid resuscitation was 0.80 (95% CI 0.28 to 22.29). Prothrombin time and partial thromboplastin time were 14.8 and 47.3 seconds in those who received a larger volume of fluid, as compared to 13.9 and 35.1 seconds in the comparison group.In the second trial (n = 110) the RR for death with a high systolic blood pressure resuscitation target (100 mm Hg) maintained with a larger volume of fluid as compared to a low systolic blood pressure resuscitation target (70 mm Hg) maintained with a smaller volume of fluid was 1.00 (95% CI 0.26 to 3.81). In the third trial (n = 25) there were no deaths.

AUTHORS' CONCLUSIONS

We found no evidence from randomised controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised controlled trials are needed to establish the most effective fluid resuscitation strategy.

Review of the rational use and adverse reactions to human serum albumin in the People's Republic of China

Human serum albumin (HSA) is an ideal natural colloid that has been widely used in clinical practice for supplemental albumin or as a plasma substitute during therapeutic plasma exchanges to redress hypoproteinemia. However, a paucity of well-designed clinical trials, a lack of a clear cut survival benefit, and frequent case reports of adverse drug reaction (ADR) make the use of HSA controversial. This study aims to review and to comment on the reported ADRs of HSA in the People's Republic of China, so as to provide the basis for rational HSA use in clinical settings. Data on the ADR case reports from HSA administration between January 1990 and December 2012 available from the China National Knowledge Infrastructure (CNKI) database, Wanfang data (WF), and Chinese Biomedical Literature (CBM) were reviewed. The reasons for using HSA, the types of ADRs, the causality of ADRs and the rationality for HSA administration were extracted and analyzed. In total, 61 cases of ADR reports were identified of which the primary disease of patients using HSA was malignant tumor (34.42%). The primary ADR was anaphylaxis (59.02%). Of the 61 cases, 30 were caused by irrational use of HSA. The most common irrational use was off-label use (56.67%), followed by inappropriate infusion rate. Therefore, we conclude that to avoid the occurrence of ADRs, guidelines for using HSA are needed to guarantee its rational use and HSA should be used strictly according to these guidelines. In addition, medical staff, including clinical pharmacists and nurses, should pay more attention to the patients who inject HSA to ensure its safe use in the clinic.

Fraud in scientific research - birth of the Concordat to uphold research integrity in the United Kingdom

Fraud in research has risen exponentially and recent high profile cases may just be the tip of the iceberg. This threatens to have a major impact on public health, with policy makers and clinicians acting on erroneous data. To address this, the new research "Concordat", a consensus statement on research misconduct, has been published. Can it hold the key to rebuilding public confidence in scientific research in the United Kingdom? This review focuses on the concept of research misconduct, highlighting prominent cases and discussing strategies in order to restore confidence in the validity of scientific research.

Intrapartum hemorrhage

Intrapartum hemorrhage is a serious and sometimes life-threatening event. Several etiologies are known and include placental abruption, uterine atony, placenta accreta, and genital tract lacerations. Prompt recognition of blood loss, identification of the source of the hemorrhage, volume resuscitation, including red blood cells and blood products when required, will result in excellent maternal outcomes.

Dose and type of crystalloid fluid therapy in adult hospitalized patients

OBJECTIVE

In this narrative review, an overview is given of the pros and cons of various crystalloid fluids used for infusion during initial resuscitation or maintenance phases in adult hospitalized patients. Special emphasis is given on dose, composition of fluids, presence of buffers (in balanced solutions) and electrolytes, according to recent literature. We also review the use of hypertonic solutions.

METHODS

We extracted relevant clinical literature in English specifically examining patient-oriented outcomes related to fluid volume and type.

RESULTS

A restrictive fluid therapy prevents complications seen with liberal, large-volume therapy, even though restrictive fluid loading with crystalloids may not demonstrate large hemodynamic effects in surgical or septic patients. Hypertonic solutions may serve the purpose of small volume resuscitation but carry the disadvantage of hypernatremia. Hypotonic solutions are contraindicated in (impending) cerebral edema, whereas hypertonic solutions are probably more helpful in ameliorating than in preventing this condition and improving outcome. Balanced solutions offer a better approach for plasma composition than unbalanced ones, and the evidence for benefits in patient morbidity and mortality is increasing, particularly by helping to prevent acute kidney injury.

CONCLUSIONS

Isotonic and hypertonic crystalloid fluids are the fluids of choice for resuscitation from hypovolemia and shock. The evidence that balanced solutions are superior to unbalanced ones is increasing. Hypertonic saline is effective in mannitol-refractory intracranial hypertension, whereas hypotonic solutions are contraindicated in this condition.

Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)

Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever, international, multidisciplinary, clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. In this review we summarize key aspects of the guideline including definition and staging of AKI, as well as evaluation and nondialytic management. Contrast-induced AKI and management of renal replacement therapy will be addressed in a separate review. Treatment recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided.

Recommendations for sepsis management in resource-limited settings

PURPOSE

To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis.

METHODS

The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings.

RESULTS

Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included.

CONCLUSION

Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries.

Fluid management and risk factors for renal dysfunction in patients with severe sepsis and/or septic shock

INTRODUCTION

The causative role of new hydroxyethyl starch (HES 130/0.4) in renal dysfunction frequency (a > 50% increase in serum creatinine or need for renal replacement therapy (RRT)) remains debated. Using the database of a multicenter study focusing on patients with severe sepsis and septic shock, the present study aimed at identifying factors associated with the occurrence of renal dysfunction.

METHODS

Among the 435 patients in a multicenter study of patients with severe sepsis and septic shock in 15 Southern French ICUs, 388 patients surviving after 24 hour, without a history of renal failure were included. Factors associated with renal dysfunction and RRT were isolated using a multivariate analysis with logistic regression.

RESULTS

Renal dysfunction was reported in 117 (33%) patients. Ninety patients required RRT. Among study participants, 379 (98%) were administered fluids in the first 24 hours of management: HES 130/0.4 only (n=39), crystalloids only (n=63), or both HES 130/0.4 and crystalloids (n=276). RRT was independently associated with the need for vasopressors and the baseline value of serum creatinine in the first 24 hours. Multivariate analysis indicated that male gender, SAPS II score, being a surgical patient, lack of decrease in SOFA score during the first 24 hours, and the interventional period of the study were independently associated with renal dysfunction. Mortality increased in the presence of renal dysfunction (48% versus 24%, P<0.01).

CONCLUSIONS

Despite being used in more than 80% of patients with severe sepsis and/or septic shock, the administration of HES 130/0.4 in the first 24 hours of management was not associated with the occurrence of renal dysfunction.

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

PURPOSE

Colloids are administered to more patients than crystalloids, although recent evidence suggests that colloids may possibly be harmful in some patients. The European Society of Intensive Care Medicine therefore assembled a task force to compile consensus recommendations based on the current best evidence for the safety and efficacy of the currently most frequently used colloids--hydroxyethyl starches (HES), gelatins and human albumin.

METHODS

Meta-analyses, systematic reviews and clinical studies of colloid use were evaluated for the treatment of volume depletion in mixed intensive care unit (ICU), cardiac surgery, head injury, sepsis and organ donor patients. Clinical endpoints included mortality, kidney function and bleeding. The relevance of concentration and dosage was also assessed. Publications from 1960 until May 2011 were included. The quality of available evidence and strength of recommendations were based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RECOMMENDATIONS AND CONCLUSIONS

We recommend not to use HES with molecular weight ≥ 200 kDa and/or degree of substitution >0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6% HES 130/0.4 or gelatin in these populations. We recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ donors. We suggest not to use hyperoncotic solutions for fluid resuscitation. We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are established.

[Volume replacement in intensive care medicine]

Volume substitution represents an essential component of intensive care medicine. The amount of fluid administered, the composition and the timing of volume replacement seem to affect the morbidity and mortality of critically ill patients. Although restrictive volume strategies bear the risk of tissue hypoperfusion and tissue hypoxia in hemodynamically unstable patients liberal strategies favour the development of avoidable hypervolemia with edema and resultant organ dysfunction. However, neither strategy has shown a consistent benefit. In order to account for the heavily varying oxygen demand of critically ill patients, a goal-directed, demand-adapted volume strategy is proposed. Using this strategy, volume replacement should be aligned to the need to restore tissue perfusion and the evidence of volume responsiveness. As the efficiency of volume resuscitation for correction of tissue hypoxia is time-dependent, preload optimization should be completed in the very first hours. Whether colloids or crystalloids are more suitable for this purpose is still controversially discussed. Nevertheless, a temporally limited use of colloids during the initial stage of tissue hypoperfusion appears to represent a strategy which uses the greater volume effect during hypovolemia while minimizing the risks for adverse reactions.

Transfusion protocol in trauma

Blood and blood components are considered drugs because they are used in the treatment of diseases. As with any drug, adverse effects may occur, necessitating careful consideration of therapy. Like any other therapeutic decision, the need for transfusion should be considered on the basis of risks and benefits and alternative treatments available to avoid over- and under-transfusion. This review is focused on the blood transfusion protocol in trauma patients with hemorrhagic shock. Besides, issues related to emergency and massive transfusion have also been elaborated. We conducted a comprehensive MEDLINE search and reviewed the relevant literature, with particular reference to emergency medical care in trauma.

Fluid resuscitation protocols for burn patients at intensive care units of the United Kingdom and Ireland

Introduction: The objective of this study was to determine the thermal injury fluid resuscitation protocols at intensive care units (ICUs) in the United Kingdom and Ireland.

Materials and methods: A telephone questionnaire was designed to survey the fluid resuscitation protocols of ICUs at all hospitals with plastic/burn surgery departments in the British Isles in 2010. The feedback from the questionnaire was from the senior nurse in charge of the ICUs.

Results: 32/64 (50%) of these ICUs had provided care to burns patients. A 100% response from these 32 units was obtained. 71.4% commence fluid resuscitation at 15% total body surface area burn (TBSA), 21.4% at 20% TBSA and 7.1% at 10% TBSA in adults. The estimated resuscitation volume was most often calculated using the Parkland/Modified Parkland formula (87.5%) or the Muir and Barclay formula (12.5%). Interestingly, of the ICUs using formulae, two had recently moved from using the Muir and Barclay formula to Parkland formula and one had recently moved from using the Parkland formula to Muir and Barclay formula. Despite this, 37.5% of ICUs using a formula did not rigidly follow it exactly. The most commonly used resuscitation fluid was Ringer’s lactate solution (46.9%) and Human Albumin Solution was used in 12.5%. No ICU used red cell concentrate as a first line fluid. 18.8% used a central line. 40.6% ICUs considered changing the IV solution during resuscitation. 78.1% ICUs consider urine output to be the most important factor in modifying resuscitation volumes. 59.4% ICUs calculate a maintenance fluid rate after completion of resuscitation. The endpoint for resuscitation was at 24 h in 46.9% ICUs and at 36 h in 9.4%. 5/32 (16%) felt their protocol gave too little and 6/32 (19%) felt their protocol gave too much. 59.3% ICUs gave oral/enteral fluids by naso-gastric or naso-jejenal tubes. 21.9% felt that oral/enteral resuscitation worked. Exactly half of the units believed that the formula that they used provided approximately the right amount of fluid, with 25% believing that it provided too much and 21.9% that it provided too little.

Discussion and conclusion: There is substantial variation in the fluid resuscitation protocols for burns of ICUs in the British Isles. The different practices demonstrated in this survey may have important consequences as inadequate fluid resuscitation can limit perfusion to potentially recoverable burns, grafted tissue and body organs not directly injured.

Fixed volume or fixed pressure: a murine model of hemorrhagic shock

It is common knowledge that severe blood loss and traumatic injury can lead to a cascade of detrimental signaling events often resulting in mortality. ^{1, 2, 3, 4, 5} These signaling events can also lead to sepsis and/or multiple organ dysfunction (MOD). ^{6, 7, 8, 9} It is critical then to investigate the causes of suppressed immune function and detrimental signaling cascades in order to develop more effective ways to help patients who suffer from traumatic injuries. ¹⁰ This fixed pressure Hemorrhagic Shock (HS) procedure, although technically challenging, is an excellent resource for investigation of these pathophysiologic conditions. ^{11, 12, 13} Advances in the assessment of biological systems, i.e. Systems Biology have enabled the scientific community to further understand complex physiologic networks and cellular communication patterns. ¹⁴ Hemorrhagic Shock has proven to be a vital tool for unveiling these cellular communication patterns as they relate to immune function. ^{15, 16, 17, 18} This procedure can be mastered! This procedure can also be used as either a fixed volume or fixed pressure approach. We adapted this technique in the murine model to enhance research in innate and adaptive immune function. ^{19, 20, 21} Due to their small size HS in mice presents unique challenges. However due to the many available mouse strains, this species represents an unparalleled resource for the study of the biologic responses. The HS model is an important model for studying cellular communication patterns and the responses of systems such as hormonal and inflammatory mediator systems, and danger signals, i.e. DAMP and PAMP upregulation as it elicits distinct responses that differ from other forms of shock. ^{22, 23, 24, 25} The development of transgenic murine strains and the induction of biologic agents to inhibit specific signaling have presented valuable opportunities to further elucidate our understanding of the up and down regulation of signal transduction after severe blood loss, i.e. HS and trauma ^{26, 27, 28, 29, 30}.

There are numerous resuscitation methods (R) in association with HS and trauma. ^{31, 32, 33, 34} A fixed volume resuscitation method of solely lactated ringer solution (LR), equal to three times the shed blood volume, is used in this model to study endogenous mechanisms such as remote organ injury and systemic inflammation. ^{35, 36, 38} This method of resuscitation is proven to be effective in evaluating the effects of HS and trauma ^{38, 39}.

[Infusion therapy for neonates, infants and children]

Intravenous administration of fluids, electrolytes and glucose are the most common interventions in hospitalized pediatric patients. Parenteral fluid administration can be life-saving, however, if used incorrectly it also carries substantial risks. Perioperatively, adequate hydration, prevention of electrolyte imbalances and maintenance of normoglycemia are the main goals of parenteral fluid therapy. Conceptionally, the distinction between maintenance requirements, deficits and ongoing loss is helpful. Although the pathophysiological basis for parenteral fluid therapy was clarified in the first half of the 20th century, some aspects still remain controversial. In newborn infants, rational parenteral fluid therapy must take into account large insensible fluid losses, adaptive changes of renal function in the first days of life and the fact that neonates do not tolerate prolonged periods of fasting. In older infants the occurrence of iatrogenic hyponatremia with the use of hypotonic solutions has led to a critical reappraisal of the validity of the Holliday-Segar method for calculating maintenance fluid requirements in the postoperative period. Pragmatically, only isotonic solutions should be used in clinical situations which are known to be associated with increases in antidiuretic hormone (ADH) secretion. In this context, it is important to realize that in contrast to lactated Ringer's solution, the use of normal saline can lead to hyperchloremic acidosis in a dose-dependent fashion. Although there is no convincing evidence that colloids are better than crystalloids, there are clinical situations where the use of the more expensive colloids seems justified. It may be reasonable to choose a solution for fluid replacement which has a composition comparable to the composition of the fluid which must be replaced. Although hypertonic saline can reduce an elevated intracranial pressure, this therapy cannot be recommended as a routine procedure because there is currently no evidence that this intervention improves long-term outcome in pediatric patients with traumatic brain injury.

[Diagnosis and management of acute mesenteric ischemia]

The prevalence of significant splanchnic arterial stenoses is increasing, but remains mostly asymptomatic due to abundant collateral circulation. Acute insufficiency of mesenteric arterial blood flow accounts for 60 to 70% of cases of mesenteric ischemia and results mostly from a superior mesenteric embolus. Despite major advances have been achieved in understanding the pathogenic mechanisms of bowel ischemia, its prognosis remains dismal with mortality rates about 60%. The diagnosis of acute mesenteric ischemia depends upon a high clinical suspicion, especially in patients with known risk factors. Rapid diagnosis is essential to prevent intestinal infarction. However, early signs and symptoms of mesenteric ischemia are non specific, and definitive diagnosis often requires radiologic examinations. Early and liberal implementation of angiography has been the major advance over the past 30 years which allowed increasing diagnostic accuracy of acute mesenteric ischemia. CT and MR-based angiographic techniques have emerged as alternatives less invasive and more accurate to analyse splanchnic vessels and evaluate bowel infarction. The goal of treatment of patients with acute mesenteric ischemia is to restore intestinal oxygenation as quickly as possible after initial management that includes rapid hemodynamic monitoring and support. Surgery should not be delayed in patients suspected of having intestinal necrosis.

Early fluid resuscitation

Solid evidence exists that fluid therapy must be started as a first-line treatment in all patients with septic shock as soon as hypotension is detected, with the goal of rapidly restoring tissue perfusion. Crystalloids or colloids can be used for initial fluid therapy, and albumin should be reserved for patients with patent or supposed hypoalbuminemia. Once fluid administration is started, its effect must be carefully monitored. In the early stages, appropriate monitoring should ensure that fluid resuscitation actually increases cardiac preload, mean arterial pressure, and tissue oxygenation. In later stages, monitoring should help to avoid fluid overload. For this purpose, the end-point of fluid therapy should not be the static values of preload indicators, but rather the disappearance of indicators of preload responsiveness. Finally, the risk of fluid overload must always be kept in mind, especially in case of lung injury.

In vitro impairment of whole blood coagulation and platelet function by hypertonic saline hydroxyethyl starch

Background

Hypertonic saline hydroxyethyl starch (HH) has been recommended for first line treatment of hemorrhagic shock. Its effects on coagulation are unclear. We studied in vitro effects of HH dilution on whole blood coagulation and platelet function. Furthermore 7.2% hypertonic saline, 6% hydroxyethylstarch (as ingredients of HH), and 0.9% saline solution (as control) were tested in comparable dilutions to estimate specific component effects of HH on coagulation.

Methods

The study was designed as experimental non-randomized comparative in vitro study. Following institutional review board approval and informed consent blood samples were taken from 10 healthy volunteers and diluted in vitro with either HH (HyperHaes^®, Fresenius Kabi, Germany), hypertonic saline (HT, 7.2% NaCl), hydroxyethylstarch (HS, HAES6%, Fresenius Kabi, Germany) or NaCl 0.9% (ISO) in a proportion of 5%, 10%, 20% and 40%. Coagulation was studied in whole blood by rotation thrombelastometry (ROTEM) after thromboplastin activation without (ExTEM) and with inhibition of thrombocyte function by cytochalasin D (FibTEM), the latter was performed to determine fibrin polymerisation alone. Values are expressed as maximal clot firmness (MCF, [mm]) and clotting time (CT, [s]). Platelet aggregation was determined by impedance aggregrometry (Multiplate) after activation with thrombin receptor-activating peptide 6 (TRAP) and quantified by the area under the aggregation curve (AUC [aggregation units (AU)/min]). Scanning electron microscopy was performed to evaluate HyperHaes induced cell shape changes of thrombocytes.

Statistics: 2-way ANOVA for repeated measurements, Bonferroni post hoc test, p < 0.01.

Results

Dilution impaired whole blood coagulation and thrombocyte aggregation in all dilutions in a dose dependent fashion. In contrast to dilution with ISO and HS, respectively, dilution with HH as well as HT almost abolished coagulation (MCF_ExTEM from 57.3 ± 4.9 mm (native) to 1.7 ± 2.2 mm (HH 40% dilution; p < 0.0001) and to 6.6 ± 3.4 mm (HT 40% dilution; p < 0.0001) and thrombocyte aggregation (AUC from 1067 ± 234 AU/mm (native) to 14.5 ± 12.5 AU/mm (HH 40% dilution; p < 0.0001) and to 20.4 ± 10.4 AU/min (HT 40% dilution; p < 0.0001) without differences between HH and HT (MCF: p = 0.452; AUC: p = 0.449).

Conclusions

HH impairs platelet function during in vitro dilution already at 5% dilution. Impairment of whole blood coagulation is significant after 10% dilution or more. This effect can be pinpointed to the platelet function impairing hypertonic saline component and to a lesser extend to fibrin polymerization inhibition by the colloid component or dilution effects.

Accordingly, repeated administration and overdosage should be avoided.

The Crystalloid versus Hydroxyethyl Starch Trial: protocol for a multi-centre randomised controlled trial of fluid resuscitation with 6% hydroxyethyl starch (130/0.4) compared to 0.9% sodium chloride (saline) in intensive care patients on mortality

PURPOSE

The intravenous fluid 6% hydroxyethyl starch (130/0.4) (6% HES 130/0.4) is used widely for resuscitation but there is limited information on its efficacy and safety. A large-scale multi-centre randomised controlled trial (CHEST) in critically ill patients is currently underway comparing fluid resuscitation with 6% HES 130/0.4 to 0.9% sodium chloride on 90-day mortality and other clinically relevant outcomes including renal injury. This report describes the study protocol.

METHODS

CHEST will recruit 7,000 patients to concealed, random, parallel assignment of either 6% HES 130/0.4 or 0.9% sodium chloride for all fluid resuscitation needs whilst in the intensive care unit (ICU). The primary outcome will be all-cause mortality at 90 days post-randomisation. Secondary outcomes will include incident renal injury, other organ failures, ICU and hospital mortality, length of ICU stay, quality of life at 6 months, health economic analyses and in patients with traumatic brain injury, functional outcome. Subgroup analyses will be conducted in four predefined subgroups. All analyses will be conducted on an intention-to-treat basis.

RESULTS AND CONCLUSIONS

The study run-in phase has been completed and the main trial commenced in April 2010. CHEST should generate results that will inform and influence prescribing of this commonly used resuscitation fluid.

Comparing the effect of hydroxyethyl starch 130/0.4 with balanced crystalloid solution on mortality and kidney failure in patients with severe sepsis (6S--Scandinavian Starch for Severe Sepsis/Septic Shock trial): study protocol, design and rationale for a double-blinded, randomised clinical trial

Background

By tradition colloid solutions have been used to obtain fast circulatory stabilisation in shock, but high molecular weight hydroxyethyl starch (HES) may cause acute kidney failure in patients with severe sepsis. Now lower molecular weight HES 130/0.4 is the preferred colloid in Scandinavian intensive care units (ICUs) and 1^st choice fluid for patients with severe sepsis. However, HES 130/0.4 is largely unstudied in patients with severe sepsis.

Methods/Design

The 6S trial will randomise 800 patients with severe sepsis in 30 Scandinavian ICUs to masked fluid resuscitation using either 6% HES 130/0.4 in Ringer's acetate or Ringer's acetate alone. The composite endpoint of 90-day mortality or end-stage kidney failure is the primary outcome measure. The secondary outcome measures are severe bleeding or allergic reactions, organ failure, acute kidney failure, days alive without renal replacement therapy or ventilator support and 28-day and 1/2- and one-year mortality. The sample size will allow the detection of a 10% absolute difference between the two groups in the composite endpoint with a power of 80%.

Discussion

The 6S trial will provide important safety and efficacy data on the use of HES 130/0.4 in patients with severe sepsis. The effects on mortality, dialysis-dependency, time on ventilator, bleeding and markers of resuscitation, metabolism, kidney failure, and coagulation will be assessed.

Trial Registration

ClinicalTrials.gov: NCT00962156

Evaluation and management of shock States: hypovolemic, distributive, and cardiogenic shock

Shock states have multiple etiologies, but all result in hypoperfusion to vital organs, which can lead to organ failure and death if not quickly and appropriately managed. Pharmacists should be familiar with cardiogenic, distributive, and hypovolemic shock and should be involved in providing safe and effective medical therapies. An accurate diagnosis is necessary to initiate appropriate lifesaving interventions and target therapeutic goals specific to the type of shock. Clinical signs and symptoms, as well as hemodynamic data, help with initial assessment and continued monitoring to provide adequate support for the patient. It is necessary to understand these hemodynamic parameters, medication mechanisms of action, and available mechanical support when developing a patient-specific treatment plan. Rapid therapeutic intervention has been proven to decrease morbidity and mortality and is crucial to providing the best patient outcomes. Pharmacists can provide their expertise in medication selection, titration, monitoring, and dose adjustment in these critically ill patients. This review will focus on parameters used to assess hemodynamic status, the major causes of shock, pathophysiologic factors that cause shock, and therapeutic interventions that should be employed to improve patient outcomes.

Year in review 2009: Critical Care--shock

The research papers on shock that have been published in Critical Care throughout 2009 are related to four major subjects: first, alterations of heart function and, second, the role of the sympathetic central nervous system during sepsis; third, the impact of hemodynamic support using vasopressin or its synthetic analog terlipressin, and different types of fluid resuscitation; as well as, fourth, experimental studies on the treatment of acute respiratory distress syndrome. The present review summarizes the key results of these studies together with a brief discussion in the context of the relevant scientific and clinical background published both in this and other journals.

Transdermal fluid loss in severely burned patients

INTRODUCTION

The skin protects against fluid and electrolyte loss. Burn injury does affect skin integrity and protection against fluid loss is lost. Thus, a systemic dehydration can be provoked by underestimation of fluid loss through burn wounds.

PURPOSE

We wanted to quantify transdermal fluid loss in burn wounds.

METHOD

Retrospective study. 40 patients admitted to a specialized burn unit were analyzed and separated in two groups without (Group A) or with (Group B) hypernatremia. Means of daily infusion-diuresis-ratio (IDR) and the relationship to totally burned surface area (TBSA) were analyzed.

RESULTS

In Group A 25 patients with a mean age of 47 ± 18 years, a mean TBSA of 23 ± 11%, and a mean abbreviated burned severity index (ABSI) score of 6.9 ± 2.1 were summarized. In Group B 15 patients with a mean age of 47 ± 22 years, a mean TBSA of 30 ± 13%, and a mean ABSI score of 8.1 ± 1.7 were included. Statistical analysis of the period from day 3 to day 6 showed a significant higher daily IDR-amount in Group A (Group A vs. Group B: 786 ± 1029 ml vs. -181 ± 1021 ml; p<0.001) and for daily IDR-TBSA-ratio (Group A vs. Group B: 40 ± 41 ml/% vs. -4 ± 36 ml/%; p<0.001).

CONCLUSIONS

There is a systemic relevant transdermal fluid loss in burn wounds after severe burn injury. Serum sodium concentration can be used to calculate need of fluid resuscitation for fluid maintenance. There is a need of an established fluid removal strategy to avoid water and electrolyte imbalances.

Resuscitation fluid use in critically ill adults: an international cross-sectional study in 391 intensive care units

Introduction

Recent evidence suggests that choice of fluid used for resuscitation may influence mortality in critically ill patients.

Methods

We conducted a cross-sectional study in 391 intensive care units across 25 countries to describe the types of fluids administered during resuscitation episodes. We used generalized estimating equations to examine the association between patient, prescriber and geographic factors and the type of fluid administered (classified as crystalloid, colloid or blood products).

Results

During the 24-hour study period, 1,955 of 5,274 (37.1%) patients received resuscitation fluid during 4,488 resuscitation episodes. The main indications for administering crystalloid or colloid were impaired perfusion (1,526/3,419 (44.6%) of episodes), or to correct abnormal vital signs (1,189/3,419 (34.8%)). Overall, colloid was administered to more patients (1,234 (23.4%) versus 782 (14.8%)) and during more episodes (2,173 (48.4%) versus 1,468 (32.7%)) than crystalloid. After adjusting for patient and prescriber characteristics, practice varied significantly between countries with country being a strong independent determinant of the type of fluid prescribed. Compared to Canada where crystalloid, colloid and blood products were administered in 35.5%, 40.6% and 28.3% of resuscitation episodes respectively, odds ratios for the prescription of crystalloid in China, Great Britain and New Zealand were 0.46 (95% confidence interval (CI) 0.30 to 0.69), 0.18 (0.10 to 0.32) and 3.43 (1.71 to 6.84) respectively; odds ratios for the prescription of colloid in China, Great Britain and New Zealand were 1.72 (1.20 to 2.47), 4.72 (2.99 to 7.44) and 0.39 (0.21 to 0.74) respectively. In contrast, choice of fluid was not influenced by measures of illness severity (for example, Acute Physiology and Chronic Health Evaluation (APACHE) II score).

Conclusions

Administration of resuscitation fluid is a common intervention in intensive care units and choice of fluid varies markedly between countries. Although colloid solutions are more expensive and may possibly be harmful in some patients, they were administered to more patients and during more resuscitation episodes than crystalloids were.