Is the use of colloids (colloidal solutions) justified in fluid resuscitation for septic patients?

Use of Colloids in Septic Patients

No, the use of colloids is not justified for initial fluid resuscitation in septic patients—crystalloids are the clear first-line choice, and synthetic colloids like hydroxyethyl starch (HES) are explicitly contraindicated due to increased mortality and renal failure. 1

Primary Recommendation

Isotonic crystalloids should be used rather than colloids (albumin or starches) as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI in sepsis. 2

• The KDIGO guidelines provide a Grade 2B recommendation for crystalloids over colloids in the absence of hemorrhagic shock 2
• Initial fluid challenge should achieve a minimum of 30 mL/kg of crystalloids 1
• Crystalloids are recommended as the initial fluid of choice in resuscitation of severe sepsis and septic shock (Grade 1B) 1

Why Synthetic Colloids Are Contraindicated

Hydroxyethyl Starch (HES)

• HES solutions are explicitly contraindicated in sepsis and septic shock due to increased mortality and renal replacement therapy requirements 1, 3
• The European Medicines Agency recommended in 2013 that HES no longer be used for volume resuscitation, particularly in sepsis patients 1, 3
• The 6S Trial demonstrated significantly increased mortality (51% vs 43%, p=0.03) and acute renal failure with HES 130/0.4 compared to Ringer's acetate 2
• The CHEST study reported increased incidence of renal replacement therapy with HES (relative risk 1.17) 3
• Meta-analyses consistently show either non-superiority or higher death rates with HES use 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

Albumin: Limited Role Only

Albumin is probably not recommended as first-line treatment in sepsis or septic shock (Grade 2-) 1

• The SAFE study (2004) showed no significant differences in mortality, ICU days, hospital days, mechanical ventilation, or days on renal replacement therapy when comparing 4% albumin to 0.9% saline 2
• Albumin may be considered only when patients require substantial amounts of crystalloids as a rescue therapy (Grade 2C) 1, 3
• The absence of clear benefit with colloids, combined with their expense and potential harms, supports the high-grade recommendation for crystalloids 1

Evidence Supporting Crystalloids

• There is no clinically important difference in survival of children treated for septic shock with colloid compared to isotonic crystalloid solutions 2
• Three randomized controlled trials in children with dengue shock syndrome and one trial in children with septic shock showed no clinically important differences in survival between colloid versus isotonic crystalloid 2
• Meta-analyses of predominantly adult patients showed no mortality differences when colloid was compared with hypertonic and isotonic crystalloid solutions 2
• Meta-analysis of trauma patients showed a 12.3% difference in mortality rate favoring crystalloid therapy 4

Clinical Algorithm for Septic Shock

1. Initial resuscitation: Use isotonic crystalloids (Ringer's acetate or normal saline) at 30 mL/kg minimum 1

2. Reassess hemodynamics: Monitor capillary refill, skin perfusion, mental status, and 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, 3

4. Never use: HES solutions or gelatins in septic patients under any circumstances 1, 3

Special Exception: Severe Dengue Shock

• For severe dengue shock syndrome specifically with pulse pressure <10 mmHg, colloid solutions may be considered when available 1, 5
• For moderate dengue shock syndrome (pulse pressure >10-20 mmHg), crystalloid solutions remain appropriate 5
• This represents the only clinical scenario in septic-type shock where colloids show specific benefit for time to resolution of shock 5

Critical Pitfalls to Avoid

• Do not use HES in any patient with severe sepsis or septic shock—this is an absolute contraindication based on increased mortality 1, 3
• Do not assume that newer "third-generation" HES 130/0.4 is safer—clinical trials had notable shortcomings including short observation periods and unsuitable control fluids 6
• Do not use colloids based on theoretical advantages of plasma volume expansion—despite theoretical benefits, HES showed no difference in fluid volume administration compared to crystalloids in the 6S trial 2
• Avoid overzealous fluid resuscitation in specialized situations like malaria-induced AKI, which may increase risk of acute lung injury 2