Blog entry by Arif Khwaja

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by Arif Khwaja - Friday, 29 June 2012, 7:24 AM
Anyone in the world

So when I was a medical student I was taught that colloids were the fluid of choice for the management of septic shock. We were not big on evidence in those days.... it was obvious, colloids expanded plasma volume much more effectively than crystalloid so why wouldn't you use colloid. Well now comes the evidence from the 6S study showing that starch is actually inferior to crystalloid. In this really well designed study  of fluid resuscitation  ICU with either 6% HES (hydroxyethyl starch)  or Ringer's acetate ( a crystalloid solution) at a dose of up to 33 ml per kilogram of ideal body weight per day. The primary outcome measure was either death or end-stage kidney failure (dependence on dialysis) at 90 days after randomization. The headline results are as follows:

At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.4 had died, as compared with 172 of 400 patients (43%) assigned to Ringer's acetate (relative risk, 1.17; 95% confidence interval [CI], 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.4 were treated with renal-replacement therapy versus 65 patients (16%) assigned to Ringer's acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09).

So clearly there is no benefit of expensive colloids over cheap crystalloids and in fact they are harmful. All very similar to the use of renal dose dopamine which made great sense on paper until people did the studies to show it was harmful....



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