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Some colloids are more equal than others: Does our choice matter?

Some colloids are more equal than others: Does our choice matter?. Sibylle A. Kozek-Langenecker Evangelic Hospital Vienna www.perioperativebleeding.org sibylle.kozek@aon.at. Cochrane Analysis 2011: … no evidence that one colloid solution is more effective or safe than any other ….

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Some colloids are more equal than others: Does our choice matter?

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  1. Some colloids are more equal than others: Does our choice matter? Sibylle A. Kozek-Langenecker Evangelic Hospital Vienna www.perioperativebleeding.org sibylle.kozek@aon.at

  2. Cochrane Analysis 2011: … no evidence that one colloid solutionis more effective or safe than any other …

  3. Cochrane Analysis 2011: …hard to see how their continued use can be justified …

  4. unjustified end point of mortality only RCTs: methodological limitations understimation of the risks of hypervolemia overestimation of direct costs for colloids inappropriate fluid monitoring & target values inadequate risks-benefits balance Why can‘t we see the difference?

  5. Colloidal fluid therapy UNI-MED Verlag AG Bremen – London – Boston 1. Auflage 2009. ISBN 978-3-8374-1184-3 2. edition in English in press

  6. Volume efficacy: HES 130 > Gelatin Van der Linden. Review. Can J Anaesth 2006;53:S30-9

  7. 800 700 660 650 700 640 580 570 600 500 400 400 400 320 280 300 200 120 100 40 0 End of Infusion 30 min 60 min 120 min HES 200/0.5, 6% Gelatin 3.5% Ringers's Lactate Effect of 500 ml volume bolus Kroll et al,. 1983

  8. Hot topic: Colloids in critical illness…effects of gelatin on kidney function unclear…… anaphylactic potential, limited volume effect compared with HES…

  9. Cardiac & stroke volume… tetrastarch superior to gelatin

  10. Cardiac & stroke volume… tetrastarch superior to albumin

  11. 12 Ringers 10 Gelatin 8 Voluven 6 4 2 0 1 3 6 9 11 15 20 25 30 35 40 45 50 55 But we WANT to use arterial blood pressure! Palacio F. 2002 Volume Preload (VP) before spinal anaesthesia for caesarean section Anzahl der Patienten mit Vasopressorbedarf Tetrastarch was superior: less vasopressor use better HD stability * *P<0.05 Time

  12. Volume efficacy HES : Gelatin 1 : 0 Choi. Crit Care Med 1999;27:200-10

  13. Microcirculation & inflammation… tetrastarch sustains pulmonary gas exchange…

  14. Pulmonary functionHES superior to gelatin Allison K. J Trauma 1999

  15. Microcirculation Pulmonary function 6% Tetrastarch : Gelatin 1 : 0

  16. HES ≠ HES

  17. Schortgen. Lancet 2001; 357: 911-916 ……… 6% hexastarch = independent risk factor

  18. VISEP studyEfficacy of Volume Substitution and Insulin Therapy in Severe Sepsis Brunkhorst. NEJM 2008; 358: 125-139 ……… 10% pentastarch: accumulation + toxicity

  19. Tetrastarch vs. Gelatin in der ICUSchabinski. Intensive Care Med 2009; 35: 1539-47

  20. Kidney function …. 6% Tetrastarch : Gelatin …. 0 : 0 Winkelmayer . Kidney Int 2003;64:1046-9 Davidson. Eur J Anaesthesiol 2006;23:721-38 Wiedermann. Intensive Care Med 2004;30:519-20 Wiedermann. Wien Klin Wochenschr 2004;116:583-94 Suttner. Anasthesiol Intensivmed Notfallmed Schmerzther 2004;39:71-7

  21. Anaphylactic reactions after colloids Laxenaire. Ann Fr Anaesth Réanim 1994 % 0.4 0.345% 0.2 0.273% 0.099% 0.058% 0 * Gelatine Dextran Albumin HES * Heta- and Pentastarch

  22. Safety: anaphylaxis HES : Gelatin 1 : 0 Barron. Arch Surg 2004;139:552-63

  23. Coagulopathy & bleeding Anesthesiology 2005;103:654. Transfus Altern Transfus Med 2007;9:173. Best Pract Res Clin Anaesth 2009; 23: 225

  24. Differences in platelet-coating capacity ADP TRAP *p<0.05 40 30 20 Mean fluorescence intensity of PAC-1 (% change) 10 0 -10 -20 Deusch. Anesth Analg 2003;97:680 * -30 * * -40 * * * saline HES 70 HES 130 HES 200 HES 450 Franz. Anesth Analg 2001;92:1402

  25. Differences between 2nd and 3rd HES generation Pooled analysis: tetrastarch versus pentastarch Kozek. Anesth Analg 2008; 107: 382

  26. 90 # 80 # 70 60 * 50 * * PAC-1 binding to platelets (% gated) 40 30 20 10 0 HES 130 HES 200 HES 450 HES 550 oxypolygelatin normal saline modified gelatin undiluted control urea-linked gelatin Differences in platelet-inhibiting capacity Thaler. Anaesthesia 2005;60:554-9

  27. Head-to-head comparison: Gelatin versus Tetrastarch 132 adult patients undergoing cardiac surgery Total Total ICU study drug red blood cell loss length of stay (mg/kg) (ml) (h) Gelatin 48.9 ± 14.6 504 ± 327 43 Tetrastarch 48.9 ± 17.2 544 ± 305 24 P N.S. N.S. N.S. Van der Linden. Anesth Analg 2005; 101: 629

  28. Small volume resuscitation 30 pigs after 60% blood volume withdrawal intervention: 4 ml/kg hypertonic saline (7.2%) / HES (6% 200/0.62) 50 ml/kg 4% gelatin 41 ml/kg 6% tetrastarch MCF blood loss HS-HES 11 mm (10,11) 725 ml (375, 900) tetrastarch 3.5 mm (2.3,4) 1600 ml (1500,1800) gelatin 4.5 mm (3,5.8) 1625 ml (1275,1950) p = 0.0034 p =0.004 Haas. Anesth Analg 2008;106:1078

  29. Meta-analysis: Gelatins versus HES Cheng. TATM 2007; 9 (Suppl): 3

  30. Meta-Analysis: Tetrastarch and gelatine unpublished data, 2011 C

  31. Head-to-head comparison… blood loss similar after tetrastarch and gelatin …

  32. Bleeding risk …. tetrastarch : gelatin …. 0 : 0

  33. Conclusion Crit Care 2010;14:325 dilutional-hyperchloremic acidosis = transient & benign

  34. Effects of potato vs. waxy maize HES on the gut mucosal microcirculation in septic rats 1200 1000 800 Red blood cell velocity (µm/s) 600 400 200 n = 2 rats per group 0 Sham CLP CLP CLP Hinkelmann J / Westphal M 2009 (unpublished data). Stero ISO Stero ISO Tetraspan Volulyte Waxy maize-derived HES and potato-derived HES are not bioequivalent, since there is clear difference in AUC and plasma clearance. Lehmann G, et al. Drugs RD 2007, 8: 229

  35. Hot topic: Colloids in pediatric patients… tetrastarch approved in children & best cost-effectiveness and safety profile….

  36. Legal aspects HES : GEL 1 : 1 Gelatin no longer approved in USA Daily dose limit for HES in Europe

  37. Some colloids are more equal than others: Does our choice matter? YES … ..our choice (on drug, timing and dosing) matters … 6% tetrastarch is more equal than gelatin: efficacy & safety 4:1

  38. Conflicts of interest Honoraria for lectures and travel reimbursement: B. Braun Fresenius Kabi

  39. 1st International ICU-Thromboprophylaxis Day 2.12.2011 in Vienna Risk factors & thromboprophylaxis - guidelines & current practice Anticoagulation despite bleeding risks Anticoagulation during extracorporeal circulation Monitoring issues Future perspective www.clotwork.at

  40. Thank you for your attention ! www.perioperativebleeding.org sibylle.kozek@aon.at

  41. Exposure to colloids and clinical outcome: Which comparison is correct? Macrocirculation: volume efficacy of gelatin 4% > tetrastarch 6% Allergic reactions: frequency after albumin > gelatins Renal failure: old HES ≥ 6% is safer than newer tetrastarch 6% Blood loss after tetrastarch is less than after pentastarch ☺

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