Bickell WH, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-1109.
- n = 598
- patients assigned to groups by alternating day
- fluid administered in field or in OT
- delayed fluid resuscitation -> reduced in-hospital mortality, fewer complications (pneumonia, ARDS, coagulopathy, wound infection, ARF), shorter stay in hospital.
- must have rapid transfer to OT
- can’t be generalized to blunt trauma
- increased risk of SIRS & MODS with uncorrected shock
Schierhout, G. et al (1998) “Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: A systematic review of randomized trials” BMJ 316:961-4
- -> mortality increase with colloids
Choi, P et al (1999) “Crystalloids vs Colloids in fluid resuscitation: A systematic review” Critical Care Medicine, 27:200-10
- -> no significant difference in pulmonary oedema, mortality or LOS in ICU
Cooper DJ, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004;291:1350-1357.
- double blind RCT
- n = 229
- traumatic brain injury + comatosed and hypotensive
- given 250mL 7.5% saline vs 250mL HMN + normal resuscitation protocols
-> no difference in survival or neurological outcome @ 6 months
SAFE Study Investigators, Finfer S, et al. A comparison of albumin and saline for fluid in the ICU. N Engl J Med 2004; 350:2247-2256.
- RCT (ANZICS)
- n = 6997
- 16 ICU’s in Australasia
- 500mL of either 4% albumin or NS
-> no difference in 28 day all cause mortality
-> no difference of new organ failure
-> no difference duration of RRT
-> no difference of mechanical ventilation
-> no difference in length of stay in ICU or hospital
-> trend to decreased mortality in albumin group in septic shock
-> trend to increase mortality in trauma patients (esp those with traumatic brain injury)
-> ratio of colloid:crystalloid to achieve the same goals found to only be 1:1.4 (against traditional teaching of 1:3)
SAFE Study Investigators (2011) “Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis” Intensive Care Medicine 37:86-96
- sub analysis of the SAFE trial (above)
- n = 1218 with severe sepsis
- albumin 4% (603) vs saline (615)
- mortality: albumin (185, 31%) vs saline (217, 35%)
-> relative risk = 0.87
-> ARR = 5%
-> NNT = 20
-> did not increase renal failure
-> no increase in other organ dysfunction
-> trend towards decreased mortality
-> good evidence to support albumin vs saline in a larger RCT
- Crystalloids vs Hydroxythyl Starch Trials
- MRCT, n = 7000
- outcomes: primary outcome mortality @ 90 days, secondary outcomes – renal failure, SOFA scores, ICU mortality, quality of life, functional status
- no significant difference in 90-day mortality (primary outcome)
- more patients who received resuscitation with HES were treated with renal-replacement therapy
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.