Is the use of colloid (colloidal solution) justified in fluid resuscitation for septic patients?

Use of Colloids in Septic Patients: Not Recommended

The use of colloid solutions for fluid resuscitation in septic patients is not justified and should be avoided, with crystalloids being the clear first-line choice for initial fluid resuscitation. 1

Synthetic Colloids: Strong Evidence Against Use

Hydroxyethyl Starches (HES)

• HES solutions are explicitly contraindicated in sepsis and septic shock due to increased mortality and renal replacement therapy requirements 1
• The VISEP and 6S trials specifically in septic patients demonstrated increased mortality (51% vs 43%, p=0.03) and acute renal failure with both high and low molecular weight HES compared to crystalloids 1
• The CHEST study (n=7,000 critically ill patients) showed increased incidence of renal replacement therapy in the HES group despite no mortality difference 1
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis patients 1
• Meta-analyses consistently show either non-superiority or higher death rates with HES use, along with increased renal replacement therapy 1

Gelatins

• Gelatins should not be used as fluid therapy in sepsis or septic shock to reduce mortality or renal replacement therapy requirement 1
• Observational studies show increased risk of renal failure with gelatins compared to isotonic crystalloids 1
• Meta-analyses suggest non-superiority of gelatins for mortality, with one showing higher incidence of anaphylactic reactions 1
• The evidence base is heterogeneous and does not support their use 1

Dextrans

• This therapeutic class has been largely abandoned due to anaphylactic and renal adverse effects 1

Albumin: Limited Role as Second-Line Agent

Evidence Summary

• Albumin is probably not recommended as first-line treatment in sepsis or septic shock to reduce mortality or renal replacement therapy requirement (GRADE 2-) 1
• Despite theoretical benefits (plasma volume expansion, anti-inflammatory properties, antioxidant effects), no high-quality study has demonstrated patient survival benefit 1
• The SAFE study (2004) and subsequent trials have not shown mortality benefit with albumin as first-line therapy 1

When Albumin May Be Considered

• Albumin may be used when patients require substantial amounts of crystalloids (GRADE 2C) 1
• This represents a weak recommendation for rescue therapy, not routine use 1
• The KDIGO guidelines recommend crystalloids over colloids, including albumin, for initial management 1

Crystalloids: The Evidence-Based Choice

Strong Recommendations

• Crystalloids are recommended as the initial fluid of choice in resuscitation of severe sepsis and septic shock (GRADE 1B) 1
• Initial fluid challenge should achieve a minimum of 30 mL/kg of crystalloids 1
• The absence of clear benefit with colloids, combined with their expense and potential harms, supports high-grade recommendation for crystalloids 1

Hemodynamic Considerations

• While crystalloids may be less efficient at stabilizing resuscitation endpoints and require larger volumes (approximately 1,775-1,985 mL more than colloids), they demonstrate superior safety profiles 2
• Central venous pressure and mean arterial pressure may be slightly lower with crystalloids, but mortality outcomes favor crystalloids over HES 2
• All-cause mortality and 90-day mortality were significantly lower with crystalloids compared to HES (relative risk 0.91, p=0.009 and 0.9, p=0.005 respectively) 2

Special Consideration: Dengue Shock Syndrome

Exception to the Rule

• For severe dengue shock syndrome specifically (pulse pressure <10 mmHg), colloid solutions may be considered when available 1, 3, 4
• For moderate dengue shock syndrome (pulse pressure >10-20 mmHg), crystalloid solutions remain appropriate 1, 3
• This represents a narrow, disease-specific exception based on evidence showing colloids reduce time to resolution of shock in dengue 5

Clinical Algorithm for Fluid Resuscitation in Sepsis

1. Initial resuscitation: Use isotonic crystalloids (Ringer's acetate, normal saline) at 30 mL/kg minimum 1
2. Reassess hemodynamics: Monitor clinical indicators (capillary refill, skin perfusion, mental status, urine output >0.5 mL/kg/hour) 1
3. If requiring large crystalloid volumes: Consider albumin only as rescue therapy when crystalloid requirements become excessive 1
4. Never use: HES solutions or gelatins in septic patients 1
5. Add vasopressors: If tissue hypoperfusion persists despite adequate fluid resuscitation 1

Critical Pitfalls to Avoid

• Do not use HES in any septic patient - this is now contraindicated by regulatory agencies and guidelines 1
• Avoid the misconception that colloids provide superior outcomes - they do not reduce mortality and may cause harm 6, 7, 8
• Do not delay crystalloid resuscitation while considering colloid options 1
• Recognize that theoretical advantages of colloids (oncotic pressure, volume expansion) have not translated to improved patient-important outcomes in sepsis 1, 6, 7
• Be aware of renal toxicity: HES and gelatins increase risk of acute kidney injury and need for renal replacement therapy 1, 9
• Monitor for coagulopathy: HES increases bleeding risk (relative risk 1.56, p=0.003) 9