What is the recommended colloid for treating an adult with hypovolemic shock?

Colloid Use in Hypovolemic Shock

Colloids are NOT recommended for hypovolemic shock—crystalloid solutions should be used as first-line therapy instead. Specifically, balanced crystalloids (such as Ringer's Lactate or Plasmalyte) are preferred over 0.9% normal saline 1.

Primary Recommendation: Avoid Colloids

The evidence strongly argues against colloid use in hypovolemic/hemorrhagic shock due to significant safety concerns without mortality benefit:

Why Colloids Should Be Avoided

Hydroxyethyl starches (HES):

• Increase renal failure risk significantly (RR 1.34, p=0.05 in the FLASH study) 1
• Cause hemostasis disorders and increase bleeding risk compared to crystalloids 1
• Lead to higher transfusion requirements in ICU settings 1
• Show NO mortality benefit despite superior volume expansion capacity (1.5:1 ratio vs crystalloids) 1
• French health authorities restricted HES to second-line use only when crystalloids are deemed insufficient 1

Gelatins:

• Meta-analyses show no mortality benefit compared to crystalloids in trauma patients 1
• No difference in renal function outcomes 1

Albumin:

• No published studies specifically support its use in hemorrhage 1
• Subgroup analysis from SAFE study (trauma without TBI) showed no benefit 1
• Significantly more expensive than crystalloids 1
• Not recommended for hemorrhagic shock 1

What TO Use: Balanced Crystalloids

Balanced crystalloids (Ringer's Lactate, Plasmalyte) are recommended over 0.9% normal saline as first-line therapy (GRADE 2+, Strong Agreement) 1:

• Reduce mortality and adverse renal events compared to normal saline 1
• Particularly important given the high volumes required in hemorrhagic shock (often 5,000-10,000 mL in first 24 hours) 1
• The SMART study showed reduced major adverse kidney events (MAKE 30) with balanced solutions 1

Clinical Algorithm

1. Initial resuscitation: Balanced crystalloid solution (Ringer's Lactate or Plasmalyte) 1
2. If crystalloids deemed insufficient: Only then consider colloids, but recognize the increased risks 1
3. Avoid albumin entirely in hemorrhagic/hypovolemic shock 1
4. Avoid HES due to renal and coagulation risks 1

Important Caveats

• The CRISTAL trial 2 showed no 28-day mortality difference between colloids and crystalloids, but 90-day mortality favored colloids (30.7% vs 34.2%, p=0.03)—however, this was an exploratory finding and the guideline consensus prioritizes the safety concerns over this single secondary outcome
• Despite colloids' theoretical advantage in volume expansion, this does NOT translate to improved clinical outcomes (mortality or composite complications) 1
• Colloid use increases risk of the "lethal triad" complications through coagulopathy 3