Colloids & Crystalloids

Antonius H. Pudjiadi

Objectives

To understand the property of colloid and crystalloid

resuscitation fluids

To know the effects of crystalloid and colloid fluids on

hemodynamic, respiratory and renal system
 DHF Grade IV

Oxygen
Immediate rapid volume replacement:
20 ml/kg isotonic crystalloid for 10-15 min, then 10 ml/kg/hour

Improvement No-improvement

Correct Acidosis, Bleeding, Calcium, Sugar

Reduce rate to 5, 3, 1.5 ml/kg respectively
further reducing to keep vein open

Hct ↑ Hct ↓
Improvement
IV colloid (Dextran 40) Whole blood 10 ml/kg or
PRC 5 ml/kg
Discontinue IV therapy for 24-48 hours

Improvement

Modified from WHO 2011

-Pr-Na
Na-Cl -Pr-Na
-Pr-Na

A B
 Distribusi Air dalamTubuh A. Pudjia!

Cairan Tubuh Total

Berat badan (%)

Cairan Intrasel

Cairan Ekstrasel

Lahir
Dewasa

Friis Hansen 1961

Mathematical Model: Male, 16 years old, Body Weight 60 kg

NaCl 0,9% 5% Albumin

1000 mL Intravascular compartment 1000 mL

Intersitial
compart- Intracellular compartment
ment

8 L 4 L 24 L 8 L 4 L 24 L

8.75 L 4.25 L 24 L 8 L 5 L 24 L
Characteristic of Colloids

Deroy, Current Anaesthesia and Critical Care (2000) 11, 20–26

N Engl J Med 2005;353:877-89

 Classic Starling Principle

Endothelial cell

Vesel Lumen
Pc πc

Pis πis Interstitium

Jv/A=Lp[(Pc-Pis)-σ(πc-πis)]

Alphonsus CS, Rodseth RN. Anaesthesia 2014;69:777-84

Revised Starling Principle

Endothelial cell
Endothelial surface layer
Pc πp
πsg Subglycocalyx space

Pis Interstitium

Jv/A=Lp[(Pc-Pis)-σ(πp-πsg)]

Alphonsus CS, Rodseth RN. Anaesthesia 2014;69:777-84

Crystalloid or colloid fluid loading and pulmonary permeability,
edema, and injury in septic and nonseptic critically ill patients
with hypovolemia

Fluid Challenge Protocol

van der Heijden M, et al. Crit Care Med 2009; 37:1275–1281

 Maric and Lemson. Br J Anaesth 2014

Crystalloid or colloid fluid loading and pulmonary permeability,

edema, and injury in septic and nonseptic critically ill patients
with hypovolemia

Colloid Crystalloid

Plasma expansion 13% 5%

Colloid Oncotic
Pressure (COP) ↑ ↓
Lung injury score
(LIS)
≋ ≋
Pulmonary Leak
Index (PLI) ↑ ↑
Extravascular ≋ ≋ Inversely related to COP-CVP (rs=-.36,p=0.40)
Lung Water(EVLW) Not related to PLI (rs=-.13, p=0.40)
Total Respiratory
Compliance ↓ ↓

van der Heijden M, et al. Crit Care Med 2009; 37:1275–1281

Crystalloid or colloid fluid loading and pulmonary permeability,
edema, and injury in septic and nonseptic critically ill patients
with hypovolemia

van der Heijden M, et al. Crit Care Med 2009; 37:1275–1281

Relationship between EVLW and (COP-CVP) Gradient

Septic with crystalloid

Septic with colloid
Non-septic with crystalloid
Non-septic with colloid

rs = - .40, p 0.01

van der Heijden M, et al. Crit Care Med 2009; 37:1275–1281

Verheij A, et al.Br J Anaesth 2006;96:21-30

Verheij A, et al.Br J Anaesth 2006;96:21-30

 Verheij A, et al.Br J Anaesth 2006;96:21-30

NaCl 0.9% Gelatin 4% HES 6% Albumin 5%

n=16 n=16 n=17 n=18
CVP (mmHg)
t0 4 (1-12) 4 (0-8) 3 (0-7) 5 (1-9)
t90 5 (2-13) 7 (3-11) 7 (4-12) 8 (4-12)
PCWP (mmHg) n=9 n=6 n=9 n=12
t0 6 (4-13) 7 (3-10) 7 (3-11) 7 (1-10)
t90 9 (5-15) 11 (7-14) 12 (9-15) 11 (8-14)
MPAP (mmHg) n=12 n=11 n=13 n=13
t0 16 (11-23) 16 (9-19) 16 (12-28) 17 (8-22)
t90 17 (12-29) 22 (14-26) 24 (17-35) 22 (15-26)
CI (l min-1m-2)
t0 3.0 (2.1-4.5 3.1 (2.2-4.8) 2.7 (1.6-4.4) 3.0 (2.7-4.7)
t90 3.1 (1.8-5.8) 3.9 (3.5-4.8) 3.9 (2.8-6.2) 3.8 (2.6-5.9)
ITBV (l min-1m-2) n=14 n=10 n=14 n=16
t0 1119 (689-1371) 1171 (938-1605) 1177 (716-1953) 1049 (641-1387)
t90 1150 (793-1513) 1277 (852-3315) 1181 (772-2164) 1189 (741-1530)
COP (mmHg)
t0 16.8 (10.5-20.6) 17.9 (13.3-21.1) 18.1 (13.5-24.9) 18.1 (13.0-23.8)
t90 15.4 (9.5-22.9) 19.8 (18.3-24.7) 21.7 (17.5-25.5) 21.2 (15.0-25.8)
LIS
t0 1.00 (0.25-2.75) 1.12 (0.25-2.00) 1.00 (0.25-2.00) 0.75 (0.25-2.00)
t90 1.00 (0.25-2.75) 1.25 (0.50-2.75) 1.00 (0.50-2.25) 1.00 (0.25-2.50)

Verheij A, et al.Br J Anaesth 2006;96:21-30

Effects of fluid resuscitation with synthetic colloids or crystalloids
alone on shock reversal, fluid balance, and patient outcomes in
patients with severe sepsis: A prospective sequential analysis

Bayer O, et al. Crit Care Med 2012; 40:2543–2551

Effects of fluid resuscitation with synthetic colloids or crystalloids

alone on shock reversal, fluid balance, and patient outcomes in
patients with severe sepsis: A prospective sequential analysis

Bayer O, et al. Crit Care Med 2012; 40:2543–2551

Effects of fluid resuscitation with synthetic colloids or crystalloids
alone on shock reversal, fluid balance, and patient outcomes in
patients with severe sepsis: A prospective sequential analysis

More fluid was needed over first 4 days

Crystalloids to HES 1.4:1
Crystalloids to gelatin 1.1:1

After day 5 fluid balance more negative in crystalloid group

Hydroxyethyl starch and gelatin were independent risk factor for acute
kidney injury
OR, 95% CI for HES 2.55 (1.76-3.69)
OR, 95% CI for gelatine 1.85 (1.31-2.62)

Bayer O, et al. Crit Care Med 2012; 40:2543–2551

Myburgh et al. N Engl J Med 2012. DOI: 10.1056/NEJMoa1209759

 Conclusions

Extravascular lung water inversely related to CVP-COP but not

related to Pulmonary Leakage Index

Both colloid and crystalloid aggravate respiratory dysfunction,

colloid have a higher risk

Hydroxyethyl starch may persuade acute kidney injury

Large randomized controlled trial comparing the use of

colloids and crystalloid for dengue shock didn’t showed
difference in mortality