Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials

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 Prior to our audit, use of Fresh Frozen plasma in newborn premature babies was used primarily for hypotension secondary to fluid depletion particularly if associated with clotting abnormalities. Given the short term benefits discussed above, in addition to the national blood donor shortages, increasing costs and focus on the emergence of blood-borne infections such as CMV and Hepatitis C; the criteria for FFP use must be tightened. In the light of the findings of the Cochrane group highlighting risks of unsubstantiated practice, until there is better evidence, there are now further reasons to refrain from the use of another blood-derived colloid, FFP.

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