Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7136.961 (Published 28 March 1998) Cite this as: BMJ 1998;316:961All rapid responses
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Sir- following the meta-analysis of Cochrane Injuries Group1 detailing the concerns on the use of albumin in intensive care setting in adults, there is also clear evidence from randomized controlled clinical trials, that there are no superior benefits of using albumin in neonates.2 However, other blood products, such as Fresh frozen plasma (FFP) in the preterm baby, frequently used for clotting abnormalities or preventing intraventricular bleeding, have equally little evidence to support their efficacy.
Apart from the Pediatric Hemotherapy Committee of the American Association of Blood Banks 19913 there appear to be no clear guidelines that exist in the literature regarding when or whether blood products should be used in the premature vulnerable baby. Our Blood Transfusion Committee which reviews the hospital use of blood and associated products do not provide specific guidance aimed at the needs of the preterm low weight neonate. Given this, the Paediatric Clinical Audit Strategy group decided to audit the use of FFP in order to construct guidelines for its use, to raise awareness, clarify our practice and compare with 'best practice as evidenced in the literature.'
We looked at all babies who received FFP over a period of 36 months (Jan 1993-Jan 1996). A total of 87 case notes of babies who had been given FFP were reviewed: median gestation 27weeks (range 24-40w); median birth weight band 1250g (range 500-3500g) of which forty four (49%) were <_1kg birth="birth" weight.="weight." of="of" the="the" _132="_132" packs="packs" minipack="50mls)" ffp="ffp" used="used" _86="_86" _65="_65" went="went" to="to" _1kg="_1kg" weight="weight" baby="baby" ie="ie" two="two" per="per" given="given" as="as" _10ml="_10ml" kg="kg" aliquots.="aliquots." in="in" past="past" has="has" also="also" thought="thought" play="play" a="a" preventative="preventative" role="role" ivh4="ivh4" and="and" some="some" units="units" continue="continue" its="its" use="use" prophylaxis.="prophylaxis." however="however" results="results" northern="northern" neonatal="neonatal" nursing="nursing" initiative="initiative" trial="trial" group5="group5" _1996="_1996" show="show" conclusively="conclusively" that="that" neither="neither" numbers="numbers" deaths="deaths" or="or" survivors="survivors" with="with" major="major" disability="disability" at="at" _2="_2" years="years" differed="differed" between="between" groups="groups" prophylactic="prophylactic" not="not" nor="nor" was="was" there="there" any="any" alteration="alteration" ivh="ivh" rate="rate" all="all" grades.="grades." our="our" audit="audit" were="were" _38="_38" _44="_44" those="those" neonates="neonates" receiving="receiving" _32="_32" had="had" grades="grades" _68="_68" normal="normal" us="us" scan.="scan." addition="addition" _90.5="_90.5" abnormal="abnormal" clotting="clotting" defined="defined" by="by" inr="inr"/>1.5 and PTTK ratio>2 and 70% were hypotensive (as defined by MAP
Ms Sue Dobinson Paediatric Audit Facilitator, Clinical Audit Department
Dr BR Pal Consultant Paediatrician, Neonatal Unit
Mr M Yegwart Chief MLSO, Blood Transfusion
Dr D Bareford Consultant Haematologist, Haematology Department
City Hospital, Dudley Road, Birmingham B18 7QH
References:
1. Schierhout G, Roberts Fluid resuscitations with colloid or crystalloid solutions in critically ill patients: a systematic review of randomized trials BMJ 1998;316:961-4
2. So KW, Fok TF, Ng PC, Wong WW, Cheung KL. Randomized controlled trial of colloid or crystalloid in hypotensive preterm infants Arch Dis Child 1997;76:F43-F6
3. Blanchette VS, Hume HA, Levy GJ, Luban NL, Strauss RG. Guidelines for auditing paediatric blood transfusion practices. Amer Journal Dis of Children 145(7):787-96, 1991 Jul
4. Beverley DW, Pitts-Tucker TJ, Congdon PJ, Arthur RJ, Tate G. Prevention of intraventricular haemorrhage by fresh frozen plasma Arch Dis Child 1985;60:170-13
5. Northern Neonatal Nursing Initiative Trial Group. Randomized trial of prophylactic early fresh-frozen plasma or gelatin or glucose in preterm babies: outcome at 2 years. Lancet 1996;348:229-32
Address for Correspondance:
Dr BR Pal, Paediatric Department, City Hospital, Dudley Road, Birmingham
Competing interests: No competing interests
Dangers of intravenous albumin infusion
EDITOR-
Two studies published in the Journal suggested that the use of
colloid, or more specifically albumin, solutions in the resuscitation of
critically ill patients may be associated with greater mortality and
morbidity than the use of crystalloids.1 2 Following media publicity
engendered by these papers, the parents of some children with the
nephrotic syndrome have expressed alarm when the question of albumin
administration was raised. Although the weight of evidence suggests that
most patients with minimal change, steroid sensitive nephrotic syndrome in
stable relapse are not hypovolaemic, there is undoubtedly a subgroup of
children who present in acute relapse with symptoms strongly suggestive of
hypovolaemia (abdominal pain, peripheral vasoconstriction, oliguria and
sometimes postural hypotension), and these symptoms are rapidly and
reliably relieved by albumin infusion. Studies of renal sodium handling
and vasoactive hormone profiles3 provide additional evidence for a state
of functional hypovolaemia in such patients, as does the finding of marked
elevation of the haemoglobin concentration and haematocrit.
The possibility that albumin infusion may be dangerous in critically
ill patients, even if true, should not lead by extrapolation to its
inappropriate withholding from nephrotic patients with clinical and
laboratory evidence of hypovolaemia, in whom it is not only effective in
relieving symptoms but may also protect against the relatively rare but
serious complications of vascular thrombosis and acute renal failure. It
is not my intention to promote the routine or casual use of albumin in
children who do not need it: indeed, the intravenous administration of
albumin to nephrotic patients who are not hypovolaemic is very dangerous.4
Albumin infusion should be considered in children in nephrotic relapse who
have symptoms and signs of hypovolaemia, supported by evidence of avid
renal sodium retention (low fractional sodium excretion, or as an
acceptable proxy, urine sodium concentration of <_10 mmol="mmol" l.="l." a="a" dose="dose" of="of" _1="_1" g="g" kg="kg" dry="dry" body="body" weight="weight" should="should" be="be" given="given" by="by" intravenous="intravenous" infusion="infusion" over="over" _4="_4" hours.="hours." the="the" patient="patient" closely="closely" monitored="monitored" and="and" stopped="stopped" frusemide="frusemide" if="if" signs="signs" volume="volume" overload="overload" appear="appear" however="however" selection="selection" is="is" appropriate="appropriate" according="according" to="to" above="above" criteria="criteria" this="this" an="an" unusual="unusual" event.="event." these="these" guidelines="guidelines" have="have" been="been" published="published" in="in" more="more" detail="detail" consensus="consensus" statement="statement" on="on" management="management" childhood="childhood" nephrotic="nephrotic" syndrome="syndrome" british="british" association="association" for="for" paediatric="paediatric" nephrology="nephrology" bapn.5="bapn.5" p="p"/> George Haycock, Professor of Paediatrics, on behalf of the British
Association for Paediatric Nephrology
Department of Paediatrics, 12th Floor, Guy's Tower, Guy's Hospital, London
SE1 9R
1 Schierhout G, Roberts I. Fluid resuscitation with colloid or
crystalloid solutions: a systematic review of randomised trials. British
Medical Journal 1998;316:961-964.
2 Cochrane Injuries Group Albumin Reviewers. Human albumin
administration in critically ill patients: systematic review of randomised
controlled trials. British Medical Journal 1998;317:235-240.
3 Vande Walle JG, Donckerwolcke RAMG, Wimersma Greidanus TB, Joles
JA, Koomans HA. Renal sodium handling in children with nephrotic relapse:
relation to hypovolaemic symptoms. Nephrology Dialysis Transplantation
1996;11:2202-2208.
4 Reid CJ, Marsh MJ, Murdoch IM, Clark G. Nephrotic syndrome in
childhood complicated by life threatening pulmonary oedema. British
Medical Journal 1996;312(7022):36-8.
5 Anonymous. Consensus statement on management and audit potential
for steroid responsive nephrotic syndrome. Report of a Workshop by the
British Association for Paediatric Nephrology and Research Unit, Royal
College of Physicians. Archives of Disease in Childhood 1994;70(2):151-7.
Competing interests: No competing interests