Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions

Ripollés, Javier; Espinosa, Ángel; Casans, Rubén; Tirado, Ana; Abad, Alfredo; Fernández, Cristina; Calvo, José

doi:10.1016/j.bjane.2014.07.018

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Review Articles • Rev. Bras. Anestesiol. 65 (4) • Aug 2015 • https://doi.org/10.1016/j.bjane.2014.07.018 copy

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions

Authorship SCIMAGO INSTITUTIONS RANKINGS

INTRODUCTION:

Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.

METHODS:

A bibliographic research was carried out in MEDLINE PubMed, EMBASE and Cochrane Library, corroborating randomized clinical trials where crystalloids are compared to colloids in GDFT for major non-cardiac surgery in adults.

RESULTS:

One hundred thirty references were found and among those 38 were selected and 29 analyzed; of these, six were included for systematic review and meta-analysis, including 390 patients. It was observed that the use of colloids is not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% CI] 3.87 [1.121-13.38]; I ² = 0.0%; p = 0.635).

CONCLUSIONS:

Because of the limitations of this meta-analysis due to the small number of randomized clinical trials and patients included, the results should be taken cautiously, and the performance of new randomized clinical trials is proposed, with enough statistical power, comparing balanced and unbalanced colloids to balanced and unbalanced crystalloids, following the protocols of GDFT, considering current guidelines and suggestions made by groups of experts.

Fluid therapy; Objective-guided fluid therapy; Colloids; Hydroxyethyl starch; Crystalloids; Systematic review; Meta-analysis

Study	Year	Randomization	Randomization sequence description	Double-blind	Blindness description	Missing description	Total	Comments
Senagore et al.²⁵	2009	1	1	1	0	0	3	Study not designed to detect complications nor effect of liquid administration
Zhang et al.²⁶	2012	1	1	0	0	1	3
Feldheiser et al.²¹	2013	1	1	1	1	1	5	Not designed to analyze complications
Yates et al.²⁷	2014	1	1	1	1	1	5
Lindroos et al.²⁸	2014	1	1	0	0	1	3	Not designed to analyze complications
Lindroos et al.²⁹	2013	1	1	0	0	1	3	Not designed to analyze complications

Study	Year	Population	Intervention	Comparer	Outcomes
Senagore et al.²⁵	2009	Adult patients Undergoing colorectal surgery	GDFT through CardioQ^® based on algorithm of maximization of SV with HES (Voluven^®); n = 21	GDFT through CardioQ^® based on algorithm of maximization of SV with Ringer lactate; n = 21	Hospital stay. Parameters of recuperation of bowel function. Complications
Zhang et al.²⁶	2012	Adult patients undergoing gastrointestinal surgery	GDFT based on optimization PPV < 10% with HE; n = 20	GDFT based on optimization of PPV < 10% with Ringer lactate; n = 20	Hospital stay. Parameters of recuperation of bowel function. Complications
Feldheiser et al.²¹	2013	Adult patients undergoing ovary surgery	GDFT through CardioQ^® based on maximization algorithm of SV with balanced HES (Volulyte^®), vasoconstrictors and inotropes for IC > 2.5; n = 24	GDFT through CardioQ^® based on maximization algorithm of SV with balanced crystalloids (Jonosteril^®), vasoconstrictors and inotropes for CI > 2.5; n = 24	Total fluids administered intraoperatively. Catecholamines administered. Hospital stay. Complications
Yates et al.²⁷	2014	Adult patients undergoing colorectal surgery	GDFT through LiDCO Rapid^® based on algorithm of optimization of SVV (SVV < 10%) with HES and dopexamine; n = 104	GDFT through LiDCO Rapid^® based on algorithm of optimization of SVV (SVV < 10%) with Ringer lactate and dopexamine; n = 98	Gastrointestinal complications on day 5. Postoperative complications. Hospital stay. Analytical parameters of coagulation
Lindroos et al.²⁸	2014	Adult patients undergoing prone neurosurgery	GDFT through Flotrac^® based on algorithm of maximization of SV with HES; n = 15	GDFT through Flotrac^® based on algorithm of maximization of SV with Ringer acetate; n = 15	Fluids necessary for hemodynamic stabilization. Coagulation changes
Lindroos et al.²⁹	2013	Adult patients undergoing neurosurgery	GDFT through Flotrac^® based on algorithm of maximization of SV with HES and vasopressors; n = 14	GDFT through Flotrac^® based on algorithm of maximization of SV with Ringer acetate and vasopressors; n = 14	Fluids necessary for hemodynamic stabilization. Coagulation changes

Study	Design	Jadad score	Conclusions	Funds	Country
Senagore et al.²⁵	Monocentric Double-blind RCT	3	The use of GDFT with CardioQ^® does is not beneficial and is more expensive than conventional. GDFT with colloids is not beneficial	Deltex medical	USA
Zhang et al.²⁶	Monocentric RCT	3	The use of GDFT with colloids improves the parameters of bowel function and decreases hospital stay	Not declared	China
Feldheiser et al.²¹	Monocentric Double-blind RCT	5	The use of GDFT with colloids provides higher hemodynamic stability, with no increase of risk of ARF, and decreases FFP transfusions	Fresenius Kabi	Germany
Yates et al.²⁷	Monocentric Double-blind RCT	5	The use of HE in GDFT does not provide crystalloid-related benefits, except for a lower balance of fluids in the first 24 h	Fresenius Kabi	United Kingdom
Lindroos et al.²⁸	Monocentric RCT	3	The use of GDFT with HES decreases the fluids administered. The administration of 400 cc of HES leads to changes in thromboelastogram	Not declared	Finland
Lindroos et al.²⁹	Monocentric RCT	3	The use of GDFT with colloids allows decreasing the perioperative administration of fluids and water balance	Helsinki University	Finland

Study	Year	Surgery	Monitoring	ASA	Age	SI duration	Risk	Describes mortality	Describes ARL	Describes complications
Senagore et al.²⁵	2009	Colorectal	CardioQ^®	ND	ND	143 vs. 150	High	Yes	No	Yes
Zhang et al.²⁶	2012	Gastrointestinal	Arterial	I/II vs. I	52.8 vs. 53.3	183 vs. 190	Low	Yes	No	Yes
Feldheiser²¹	2013	Gynecological	CardioQ^®	II/III vs. III	58 vs. 52	272 vs. 242	Moderate-High	Yes	Yes	Yes
Yates et al.²⁷	2014	Colorectal	LiDCO Rapid^®	II vs. II	72 vs. 70	ND	Moderate-High	Yes	Yes	Yes
Lindroos et al.²⁸	2014	Neurosurgery	Flotrac^®	II vs. II	55 vs. 52	169 vs. 132	High	No	No	No
Lindroos et al.²⁹	2013	Neurosurgery	Flotrac^®	III vs. III	40 vs. 43	145 vs. 146	High	Yes	No	Yes

Study	N	Reason for exclusion
Krebbel et al.³¹	40	Balanced and unbalanced solutions are compared
Kotake et al.³²	35	A colloid different from HE 6%: 130/0.4 is used
L’Hermite et al.³³	56	Does not include complications or mortality as primary result
Dehne et al.³⁴	60	A colloid different from HE 6%: 130/0.4 is used. GDFT is not performed
Godet et al.³⁵	65	GDFT is not performed
Guo et al.³⁶	42	A colloid different from HE 6%: 130/0.4 is used. GDFT is not performed
Hung et al.²³	84	GDFT is not performed

Sociedade Brasileira de Anestesiologia R. Professor Alfredo Gomes, 36, 22251-080 Botafogo RJ Brasil, Tel: +55 21 2537-8100, Fax: +55 21 2537-8188 - Campinas - SP - Brazil
E-mail: bjan@sbahq.org

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[1] * Corresponding author. E-mails: ripo542@gmail.com, ripo542@hotmail.com (J. Ripollés)