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No Short-term Mortality Benefit with Use of Colloids over Crystalloids for Fluid Resuscitation in the ICU (CRISTAL)


 

Clinical question

As compared with crystalloid therapy, does the use of colloid solutions for fluid resuscitation in the intensive care unit improve mortality in critically ill patients with hypovolemic shock?

Bottom line

For critically ill patients with acute hypovolemic shock, the use of colloid solutions for fluid resuscitation does not significantly affect short-term mortality as compared with the use of crystalloid solutions. However, the data suggest that deaths over 90 days may be reduced with colloids. More research is needed to confirm these findings. (LOE = 1b-)

Reference

Annane D, Siami S, Jaber S, et al, for the CRISTAL Investigators. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock. JAMA 2013:310(17);1809-1817.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (ICU only)

Synopsis

Critically ill patients with acute hypovolemia were randomized, using concealed allocation, to receive fluid resuscitation with crystalloids or colloids. Patients who had already received fluid resuscitation while in the intensive care unit (ICU) were excluded from the study. Randomization was stratified according to diagnosis: sepsis, trauma, or other causes of hypovolemic shock. In the crystalloid group, patients received isotonic or hypertonic saline or other buffered solutions; patients in the colloid group received hypo- or hyper-oncotic solutions such as gelatins, dextrans, hydroxyethyl starches, or albumin. The amount and duration of fluid resuscitation was left to the discretion of the clinicians. Clinicians were not masked as it was considered infeasible to stock the units with adequately masked fluid solutions, especially for the use in emergencies. Analysis was by intention to treat. Baseline characteristics in the 2 groups were similar. The median age was 63 years and the majority of patients had hypovolemia due to sepsis. The median volume of fluid administered (excluding maintenance therapy) during the first 7 days in the ICU was higher in the crystalloid group (3 L vs 2 L; P < .001). For the primary outcome of mortality at 28 days, there was no significant difference detected between the 2 groups. Although there were fewer deaths in the colloid group at 90 days, this was a secondary outcome and the confidence interval approached 1 (31% vs. 34%; relative risk = 0.92; 95% CI, 0.86-0.99; P = .03). At the 28-day mark, patients in the colloid group were more likely to be alive without the need for mechanical ventilation (14.6 days vs 13.5 days; P = .01) or vasopressor therapy (16.2 days vs 15.2 days; P = .03).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

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