Fluid Therapy Literature Summaries

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)
  MRCT (Australasian)
• 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

CHEST Trial

• 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