New Clinical Aspects Of Volume

Therapy with Colloids

Kuala Lumpur, Malaysia
16.05.2005

Compiled by Dr. Elmar Rudolph, M.D.,

Physician, Germany
Director Medical Affairs A/P
BMI

An Educational Service provided by:

New Clinical Aspects Of Volume

Therapy with Colloids
Trong Khach Hotel, Hai Phong,
Vietnam
27.04.2005

Compiled by Dr. Elmar Rudolph, M.D.,

Physician, Germany
Director Medical Affairs A/P
BMI

An Educational Service provided by:

Volume Therapy is
important!
In the USA:

24 million operations a year

1.5% die (360 000 death)
Of these, 80% die because of
insufficient volume therapy (288 000
death)
This can be avoided in the majority
by non-invasive monitoring and by

colloid therapy
(Shoemaker, W.)

Which colloid
for which
indication?

1902:
Shock:

a state of general depression of

the nervous system induced by a
severe injury or by a powerful
disturbance of the emotional
centres.

Carr, JW. The Practitioners Guide. New York: Longmans, 1902; 865-66.

Adams H.A. et al.: Intensivmed 38:541-553 (2001):

Hypovolemic shock is a state of

insufficient perfusion of vital organs with
consecutive
imbalance of oxygen supply and demand
due to an intravascular volume
deficiency

Definitions of shock types:

Hypovolemic
shock
Cardiogenic
shock

Neurogenic
shock
Anaphylactic
shock

Septic
shock

Diagnosis of Shock
Early Recognition
Physiological
Diagnosis
Subjective Symptoms
and
Imprecise Signs:

Objective Hemodynamic Criteria:

Weak, thready
Hypotension
pulse
Acidosis
Cold, clammy skin
Oliguria
Altered mental
Collapse
status
Reduced Oxygen
Unstable vital
Delivery
signs
Dilemma: The criteria for recognition are not the criteria for
Cyanosis
diagnosis

Modified after W. Shoemaker

Physiology

Diagnosis

Hypovolaemic shockBleeding

Cardiogenic shock
Complex shock

Distributive shock

Obstructive shock

GI losses
Reperfusion injury
Burns
Septis
Myocardial infarction
Cardiomyopathy
Valvular heart disease
Septis
Burns
Septis
Burns
Anaphylactic
Neurogenic
Reperfusion
Tensionpneumothorax
Pulmonary embolus
Cardiac tamponade

Traumatic
Hemorrhagic
Shock

Forms of Hypovolemic Shock

Hemorrhagic shock
(controlled/uncontrolled)

due to acute blood loss without major tissue damage

Hypovolemic shock (spec.) due to critical decrease

of
circulating plasma volume without acute bleeding

Traumatic-hemorrhagic shock
(controlled/uncontrolled) due to acute bleeding

and major tissue damage with mediator release

Traumatic-hypovolemic shock due to critical

decrease of circulating plasma volume and major tissue

damage without acute bleeding, with mediator release

Forms of Hypovolemic Shock

Hemorrhagic shock
(controlled/uncontrolled)
(internal/external bleeding due to stabbing, gun shots, bursting of an aneurysm, extra uterine pregnancy, tumors, oesophagus varices)

Hypovolemic
(external/internal fluid loss,shock
inadequate fluid intake, high temperature, diarrhea,
vomiting, renal fluid loss due to diabetes, renal failure, intern. due to ileus, peritonitis,
liver cirrhosis, pancreatitis et al.)

Traumatic-hemorrhagic shock
(controlled/uncontrolled) (major tissue damage, major trauma,
consecutive systemic reaction, decreased circulating blood volume, organ dysfunction
(SIRS)

Traumatic-hypovolemic shock

(critical decrease of circulating plasma volume e.g. due to major burns, skin abrasions
or acid burn, reduced preload, reduced stroke volume, tissue hypoxia,inflammatory
reaction, SIRS)

Hydrostatic pres sure (mmHg)

The Starling hypothesis

Arteriole

35

P1

Interstitial
space

Venule

Capillary

25
15

P2
Drainage by the lymphatic system
P1= hydrostatic pressure at the proximal end of the capillary
P2= hydrostatic pressure at the distal end of the capillary

Indications for Synthetic

Colloids
Absol. Hypovolaemia
(haemorrhagic shock)
Perioperative blood losses
Relative hypovolemia (anaesthesia , severe
sepsis )
Burns
Blood saving techniques
Priming of the heart-lung machine
Plasmapheresis
Therapeutic Hemodilution (stroke hearing

Pure
Crystalloid
Therapy?

Separation of Total Body Water

Osmotic and Colloid-Osmotic Pressure
(Starling 1896)

( COP )

TBW
ICS
280
K-ions
mOsm/l

EC
280S
Na-ions
mOsm/l
Intravascular space
COP ~25 mm
TP
Hg- 80% Albumin

Interstitial
space
COP~
5mmHg

Edema threshold : COP 20-15 mmHg - Albumin 2.5 g/dl - TP 5.0 g/dl (??)
Normal values : Albumin 3.5 - 5.5 g/dl, TP 6.0 - 8.0 g/dl

Crystalloid solutions and haemorrhagic shock

Cervera, A. L. et al., J. Trauma 14 (1974) 506520

Ratio crystalloid infusion / blood loss

Prediction

Prediction

Measurement

14121086420-

Blood loss
10 20 30 40 50 60 70 80
(%)

Isovolemic Hemodilution - Colloid vers.Crystalloid

Funk, W. Baldinger, V.: Microcirculatory
(4x) Perfusion during Volume
CBF-Coll

CBF-Crys
Crys

pO2-Coll

pO2-

25

0,8

20

0,6

15

0,4

10
5

0,2
0

Baseline

0
End of HD

60 min later

30 syrian golden hamsters, hemodilution (HD) of~20ml/kgBW

Capillary blood flow (CBF) and tissue pO
, HCT after HD: 30%
2

p O 2 ( m m H g)

CBF (mm/s)

1,0

Therapy.
Anesthesiology
82 (1995) 975 982

Postoperative Fluid Overload in Cardiac Surgery:

An Indicator of Mortality
Lowell, Crit Care Med 18:728, 1990

<10%
10-20%
>20%

Gain
Of
Body
Water

Mortality (%)

0 10 20 30 40 50 60 70 80 90 100

DO2 and survival in high-risk surgical

patients
(%)

168 patients in the control and 101 in

the study group.

40
29%
20

In control group CI = 2.8-3.5 l x min-1 x

m-2 and DO2 = 400-550 ml x min-1 x m-2
16%

In study group CI > 4.5 l x min-1 x m-2

and
DO2 > 600 ml x min-1 x m-2
Deaths in control group

0
p < 0.05

Deaths in study group

W. C. Shoemaker et al., Chest 94 (1988) 11761186

Oxygen Transport Capacity (%)

(under condition of Normovolemia)
Hemodilution

Hemoconcentration

(%) 120
100

Oxygen Transport
Capacity

80
60
40
20
0
0

10

20

30

40

50

60

70

80 (%)

Hematocrit
Modified after Sunder-Plassmann et al., Anaesthesist 20 (1971) 172

Normovolemia
Crystalloi
ds
Lactated
Ringer's,

Colloids
n
a
t
u
r
a
l

Albumin
FFP

Normal
Saline

Gelatin
HES
Dextran

s
y
n
t
h
e
t
i
c

Volume Therapy with both: Crystalloids and Colloids

Synthetic
Colloids

Demands on an ideal Synthetic

Colloids:

(which
not exist!)
9 inexpensive and
freedoes
of infectious
agents

9 available in unlimited quantities

9 stable for long periods of time
9 colloid osmotic pressure and viscosity like plasma
9 completely degradable and eliminated via kidneys
9 no longtime storage in the organs
9 No negative impact on liver- kidney or immune
function
9 sufficient volume effect and duration
9 free of coagulation disorders
9

The formula unit of HES

R11 = glucose or
--CH
CH22- CH22--OH
OH

6
CH22--O-R
O-R11
H

H
OH H
O
-CH22- CH22--OH
O-CH

4
O
R22--O

R22 = glucose

1
2

O
-R22
O-R

OH
O
-CH22- CH22--OH
O-CH

Not all synthetic colloids are

the same!
The mean molecular weight (Mw),
the degree of substitution (DS) with
hydroxyethyl groups (HES), the crosslinking agents (GEL) and the
concentration of colloids in solutions
determine the pharmacokinetic and
dynamic!

Degree of Substitution
(DS)

Glucose unit

-CH2- CH2-OH

DS = 5/10 = 0.5

The higher the DS, the stronger the resistance against aamylase degradation, the longer the intravascular duration!

HES = Hydroxethylstarch
(Not all HES are the same!)

1.

(Based on degree of substitution)

Tetrastarch (0.4)

HES 130 /0.4

2.

Pentastarch
(0.5)
HES 200 /0.5

Hetastarch (0.7)

HES 450 /0.7

(Based on Molecular weight)

High molecular weight

HES

Medium Molecular weight

HES

Low molecular weight

HES

HES 450 / 0.7

HES 470 /0.7

HES 200 /0.5

HES 200 /0.62

Hespan
Plasmasteril

Hemohes,
Haes-steril
Elohes
Pentaspan

HES 40 /0.5
HES 70 /0,5
HES 110 /0,5
HES 130 /0,4
Hespander,
Rheohes,
Voluven

Gelatin Solutions

Not all Gelatin Solutions are the same!

4%

3.5%

Modified Fluid Gelatin Polygeline

(MFG)
(urea linked/
(succinylated)
diisocyanate)

Gelofusine,
Gelafundin,
Mw= 30 000 dalton

Haemaccel
Mw= 35 000

4%

Oxypolygeli
ne
(OPG)

Gelifundol
Mw= 30 000

Dextran Solutions:
Low molecular Dextran

High molecular Dextr

Dextran 40

Dextran 60
Dextran 70
Dextran 75

Rheomacrodex
Plasmacair

Macrodex
Hemodex

(-)
(-)
(-)

(-)

(-)
(-)

(-)

(-)

(-)
(-)

(-)

(-)
(-)

(-)

(-)
(-)

(-)

(-)

(-)

Repelling Effect:
Negatively charged
endothelial cells repel
negatively charged
Gelatin molecules
Result: Longer and
Stronger Volume effec

In vitro colloid osmotic (C0P) pressure of colloids

(diffusibility)
(mm Hg)
50
COP50

COP10

0.5

COP50
/COP10

0.4

0.37 0.36

42.3
40

30

20

10

26.5
17.6

15.6

6.3 4.9

0.3
0.18

0.2

0.1

A. R. Webb et al., Intens. Care Med. 15 (1989) 116116-120

Setting:

- In vitro
measurement of
COP of different
colloidal volume
replacement
solutions with an
oncometer, using
membranes with a
cut-off point of
50000 and 10000
Dalton respectively.
Gelofusine (MFG)
4.5% Human albumin
Haemaccel
p < 0.001 A, B vs. C

MFG has similar COP properties like Human Albumin!

Volume effects of
colloids

Zornow, MH et al.: Fluid Management In Patients

With Traumatic Brain Injury. New Horizons 3:488498, 1995
(added by presenter)

5% Albumin

Increased
PV
(ml)
1,000

Infused
volume
(ml)
1,000

Increased Increased
ISS (ml)
ICV (ml)

25% Albumin

1,000

250

-750

5% Dextrose

1,000

14,000

3,700

RL

1,000

4,700

3,700

HES 200/0.5 6%

1,000

1,000

MFG 4%

1,000

1,000

Dextran 40 10%

1,000

500-600

9,300

-400/-500

PV plasma volume;ISS interstitial fluid volume;ICV intracellular volume;RL lactated Ringers

solution MFG=modified fluid gelatin

Average initial volume effect /average

duration of volume effect
(in hypovolemic volunteers)
3.5 % Polygeline

~70% ~2-3h

4% Modified Fluid Gelatin

6% HES 200/0.5

50

100

Same effect
and duration!

~ 100 % ~3-4h

6% Dextran 70
6% HES 200/0.62 and HES 450/0.7
10% HES 200/0.45 and 0.5
10% Dextran 40

(?)
1oo%

(?)
150

~ 4h
~ 7-9h
~ 4h

145 %

~ 190 % ~ 3-4h
200 (%)

% of max. concentration

Pharmacokinetic of Hydroxyethylstarch
100

80

60

40

t *

20

HES 450/0,7
HES 200/0,62
HES 200/0,5

0
0.5

4 6 12

24

33

hours after infusion

120 246

GEL

Volume effects of different

Setting
Setting
colloids
-- Withdrawal
Withdrawal of
of 375
375 ++ 25
25 ml
ml

Setting
Setting
-- 20
20 ventilated
ventilated ICU
ICU patients.
patients.
-- Infusion
Infusion of
of 500
500 ml
ml of
of
6%
HES
200/0.5
over
6% HES 200/0.5 over
30
30 minutes.
minutes.
Method:
Method: carbon
carbon monoxide
monoxide

of
of blood
blood and
and substitution
substitution
with
500
ml
with 500 ml of
of
gelatin-based volume
gelatin
gelatin-based
volume
replacement
replacement fluid
fluid in
in healthy
healthy
volunteers.
volunteers.

4%
4%
Gelofusine
Gelofusine

HES2oo/0.5
HES2oo/0.5 6%
6%

O.
-183
haematol
171
O. Giebel
Giebel et
et al.,
al., Bibl.
Bibl. haematol.
haematol.. 33
33 (1969)
(1969) 171171-183

pp << 0.05
0.05
P.
-420
Anaesthesiol
414
P. Christensen
Christensen et
et al.,
al., Acta
Acta Anaesthesiol.
Anaesthesiol.. Scand.
Scand. 45
45 (2001)
(2001) 414414-420

(ml
(ml
)600
)600

11 hh

33 hh

4h
(ml)
(ml)
500
500
450
450
400
400
350
350
300
300

500
500
400
400
300
300
00

10
10

30
30

60
60

120
120

180
180 (min)
(min)

250
250
200
200
00

(h)

Volume effects of different

Setting
Setting
colloids
-- Withdrawal
Withdrawal of
of 375
375 ++ 25
25 ml
ml

Setting
Setting
-- 20
20 ventilated
ventilated ICU
ICU patients.
patients.
-- Infusion
Infusion of
of 500
500 ml
ml of
of
6%
HES
200/0.5
over
6% HES 200/0.5 over
30
30 minutes.
minutes.
Method:
Method: carbon
carbon monoxide
monoxide

of
of blood
blood and
and substitution
substitution
with
500
ml
with 500 ml of
of
gelatin-based volume
gelatin
gelatin-based
volume
replacement
replacement fluid
fluid in
in healthy
healthy
volunteers.
volunteers.

Gelofusine
(MFG)
Gelofusine
(MFG)

HES
HES 2oo/0.5
2oo/0.5 6%
6%

Polygeline
Polygeline
O.
-183
haematol
171
O. Giebel
Giebel et
et al.,
al., Bibl.
Bibl. haematol.
haematol.. 33
33 (1969)
(1969) 171171-183

P.
-420
Anaesthesiol
414
P. Christensen
Christensen et
et al.,
al., Acta
Acta Anaesthesiol.
Anaesthesiol.. Scand.
Scand. 45
45 (2001)
(2001) 414414-420

(ml)
(ml)
600
600

11 hh

33 hh

4h

ml
ml
500
500
450
450
400
400
350
350
300
300

500
500
400
400
300
300
00
(min)
(min) 10
10 30
30

60
120
60 120

180
180

240
240

250
250
200
200
00

(h)

Molecular Shape of Semi-Synthetic

Gelatins
--

---

--

--

--

--

--

--

--

--

--

--

--

---

--

--

-- ---

--

--

--

---

---

--

--

Succinylated, negatively
charged
Modified Fluid Gelatin
(Gelofusine)

Urea-linked Polygeline
(Haemaccel)

Elimination kinetics of HES 450/0.7 and HES

200/0.5
(%)
100
80

HES 450/0.7

HES 200/0.5

20

25

54

35

35

35

30

47

10
15

60

65

40

33

20
0

Setting:
- 10 healthy volunteers.
- infusion of 30 g of
HES 450/0.7 or of
50 g of HES 200/0.5.

70

6h

60

12
h

13

35

10
days

6h

18

12
h

Deficit of
detection
urine
plasma

10
days

F. Asskali, Beitr. Anaesth. Intensivmed. 26 (1988) 43-53

In contrast: Gelatins are without any longtime

storage
completely eliminated within 2 days!

Haisch, G. et al.:
The influence of Intravascular Volume Therapy with a New
Hydroxyethyl Starch (6% HES 130/0.4) compared to 4% Modified Fluid Gelatin
Anesth Analg 2001,92,pp 565-71
Study design: Prospective randomized study in 42 patients undergoing major abdominal surgery.

Crystalloids

Colloids

4% Gelofusine
6% HES 130/0.4

Urine
Drainage
blood loss

2000

4000
mL

6000

No differences between 4%
MFG and 6% HES 130/0.4 with
respect to:
- hemodynamic parameters
- volume of colloids
- volume of crystalloids
- postoperative blood loss
- urine output

Human
Albumin?

Facts about Albumin

Serum albumin is a poor nutritional
marker
Albumin is a good prognostic
marker correlating with morbidity
and mortality
IV albumin does not improve
outcome
IV albumin is not cost-effective

Therapeutic Use of Albumin

Alexander, M.R. et al., University of Iowa
.JAMA, Feb 12, 1982 -Vol 247, No. 6

(units)

S: Surgical use

1977

M: Medical use

1980

Costs: $101,60 versus $15,498

(After implementation of an Albumin prescription form)

Albumin Supplementation in the

Critically ill
Eugene F. Foley et al. , Arch Surg-Vol 125, June 1990
Harvard University Medical School, Boston, Mass.

40 hypalbuminemic, critically ill patients, (serum albumin <2,5g/dl)

Treatment group (n=18) received 25% albumin, No Treatment group
(n=22)

(%)

(d)

100
90
80
70
60
50
40
30
20
10
0

45
40
35
30
25
20
15
10
5

Mortality Complication

Treatment

No Treatment

Hospital

ICU

Ventilat.

Postoperative Human Albumin

Therapy
Grundmann, R. et al.
Langenbecks Arch Chir (1986) 367:235-246

n=161

(%)

120
100
80
60
40
20
0

Therapy group (n=81): i.v. Albumin at COP < 19mmHg

Therapy

Control
p=0,008
p=0,018

n.s.

n.s.

n.s

Compliction. Reoperation Mortality Vent.

Antibio.

Human albumin administration in

critically ill patients:
Systematic review of randomized controlled trials
Cochrane Injuries Group Albumin Reviewers
BMJ Volume 317 25 July 1998

Subject: 30 trials including 1419 patients

Results: For every 17 critically ill patients treated
with albumin is one additional death! (83 death)

Human albumin administration in

critically ill patients:
Systematic review of randomized controlled trials
BMJ Volume 317 25 July 1998

Conclusion: .......that albumin may increase mortality.

The use of human albumin in critically ill patients
should be urgently reviewed.
It should not be used outside the context of rigorously
conducted, randomized controlled trials.

Colloids and
Renal Function

Calcium in Polygeline
Calcium in Polygeline: unimportant for the volume effect!
Makes Polygeline incompatible with citrated blood and
FFP (1).
Induces severe hypercalcaemia even at moderate
dosages (2).
Increases the nephrotoxicity of gentamycin 3).

1) F. Murray and P. Hutton, Anaesthesia 44 (1989) 392-393

2) P. A. Evans et al., J Accid Emerg Med14 (1997) 73-75
3) M. Schneider et al., Anaesth Intens Care 24 (1996) 647-650

Schneider,M. et al, Anaesth Intens Care 1996; 24: 647-650

Royal Perth Hospital, W.A.

Acute Renal Failure in Cardiac Surgical

Patients, Potentiated by Gentamicin &
Calcium
273 patients undergoing coronary artery bypass operation.

Results:
Patients who received both Polygelin (calcium: 6.25 mmol)
in the bypass prime and Gentamicin had a higher incidence
of renal failure.

Incidence of acute renal failure

Bypass
Prime

A (n=91)

Polygelin
+ Crystalloid

Antibiotic
Gentamicin
Prophylaxis +Flucloxacillin

B (n=72)

C (n=57)

Polygelin
Crystalloid
+Crystalloid
+Albumin
Cephalothin Gentamicin

Schneider, M. et al Anaesth Intens Care 1996; 24: 647-650

D (n=47)

Crystalloid
+Albumin

Cephalothin

Cittanova, ML. et al.:

Lancet / 348 / 9042 (1620-1622) 1996

Effect of Hydroxyethylstarch in brain-dead Kidney Donors

on Renal Function in Kidney-transplant Recipients
69 brain-dead patients :
In 27 cases kidneys were procured
group 1 = HES up to 33ml/kg (n=15)
group 2 =
Gelatin infusions (n=12)

HE
GEL
S

5%
HES
GEL
Requirement ofof
external
haemodialysis
haemodiafiltration
Requirement
Hemodialysis
ororHemodiafiltratration
after kidney transplantation

HES should not be used in University of Wisconsin organ-preservation

solution any more due to high viscosity and HES-induced RBC
aggregation!

HES causes high viscosity

HES causes RBC aggregation

y
y
y
function in severe sepsis: a multicenter randomised
study
Schortgen, F. et al.: LANCET, 357 (9260) 911-6/2001 Mar 24
Setting:Adults with severe sepsis or septic shock (n=129). Endpoint was Acute Renal Failure
ARF
(a two-fold increase
in serum creatinine from baseline or need for renal replacement
45
(%)
therapy)
40
35
30

P=0.02

25

HES
GEL

20
15
10
5
0

Acute Renal Failure

Conclusion: The use of Hydroxyethylstarch is an

independent risk factor for ARF in patients with severe sepsis
or septic shock!

Leuschner, J. et al. Fresenius Clinical Research, Bad Homburg,

Germany:

Tissue Storage of C14 Labelled HES 130/0.4 and

HES 200/0.5 after Repeated Intravenous
Administration to Rats
Drugs R&D 2003, 4(6);331-338

Radioaktivity in the kidneys as percentage of the total

administered dosage
15.00%
10.00%
5.00%
0.00%

3 days

10 days
HES 130

24 days
HES 200

52 days

Accumulation of HES in Patients

under Hemodialysis
(g/l)
15

10

10

12

Administration of 2 x
500 ml per week of
Gelatin or Hetastarch
before hemodialysis.

7
0.5
week 1

0.5
week 2

0.5
week 3

H. Khler, Fortschr. Med. 97 (1979) 18091813

Gelati
n
Hetastarch

Colloids and
Coagulation Disorders

Effects of PVR solutions on

haemostasis and coagulation
Gelatins
Factor VIII, vWF
Platelets
adhesion
aggregation
Thrombus
formation tim
e
Blood typing

HES

Dextrans

No effect
No
effect
No clinical
effect
No effect

In emergency situations
blood typing prior to infusion

Does intraoperative Hetastarch administration increase blood

loss and transfusion requirements after cardiac surgery?
Knutson, J.E. et al.: Anesthesia and Analgesia;90;4;801-7;2000
Setting: Retrospective chart review (n=444) on cardiac surgical patients who intraoperatively
recieved Hetastarch (n=234) or not (n=210).
HES
(ml)
Control
P<0.001

1400
1200
1000

P<0.001

800
600
400
200
0

0-4 h postop.

0-24 h postop.

The authors conclude, that intraoperative use of Hetastarch in primary

cardiac surgery may increase bleeding and transfusion requirements.

Pentastarch versus albumin in

cardiopulmonary bypass prime: Impact on
blood loss
Keyser, EJ et al.
Journal of Cardiac Surgery/ 14/4 (279-286) 1999
Group P: n=100, 750ml Pentastarch 10% in 1000ml Ringers solution
Group A: n=100, 200ml Albumin 25% in 1500ml Ringers solution
4000
3500

(ml
)

3000
2500
2000
1500
1000
500
0

Blood loss

CONCLUSION: The diminished coagulability associated with

Pentastarch in
this dose resulted in increased postoperative bleeding.

Volume replacement in primary total hip

replacement: 4% Gelatin versus 6% HES
200/0.5
Setting

Blood loss and tailored

haemotherapy
(ml)
4000

3000

n. s.
Alb.
342
Cryst
. 881

1000

p< 0.05

Alb.
324
Cryst
. 1033

2000
Coll.
2131

Loss

Intak
e

Coll.
2119

n. s.
PRB
C*
459
Ec 229*
Aut.
bl. 857

PRB
C*
355
Ec 373*
Aut.
bl. 959

Blood
2778

Blood
3437

- 2 groups of 21 patients
each
- Preoperative
normovolaemic
haemodilution (1 l of blood
out,
1 l of colloid in, either MFG
or
HES 200/0.5)
-Further fluids (crystalloids,
colloids) and haemotherapy
(autologous blood, PRBC,
red
blood cells from cell saver)
as
MFG
HES 200/0.5
required

Y. J. Mortelmans et al., Anesth. Analg. 81 (1995) 1235-No hemodynamic

1242
differences between

Volume replacement in major

orthopaedic surgery: MFG versus
HES
200/0.5
(l) CRYST
COLL
PRBC
FF
Setting
6

5.5 5.5

5
4
3

-Tailored haemotherapy
allowing for Hkt ~ 25%
and use of colloid, PRC

3.0 2.9

3.0
2.5

2
1.0 1.0

1
0
n. s.

n. s.

n. s.

- 19 patients in 6% HES
and 22 in MFG group
- 3 ml/kg . h crystalloid
- cell saver use

n. s.

R. Beyer et al., Br. J. Anaesth. 78 (1997) 4450

-No hemodynamic
differences between
groups

MFG
HES
200/0.5

The Effect of the Combined Administration of Colloids on the

Coagulation System: An In Vitro Study Using
Thrombelastograph Coagulation Analysis
Fries D. et al. Anesth Analg 2002,94:1280-7

of CFT (s)

(n.s)

200
150
100
50

(Clot Formation Time)

0
MFGEL

40%Dilution
HES 130

HES 200

MFG/HES 130

MFG/HES 200

MFGEL= Modified Fluid Gelatin, HES= Hydroxyethyl Starch,

D of CFT (s) = Changes over baseline of Clot Formation Time in seconds after 40% dilution
with blood
Conclusion: Bleeding could be reduced by the selection of Gelatin solutions rather than
HES solutions, when larger volumes of colloids are required or the maximal dose of HES
has been administered

Van der Linden, PJ et al.: Gelatine is as effective as 6% HES

200/0.5 for volume management in cardiac surgery patients
Canadian Journal of Anaesthesia; Vol: 51(3); p. 236-41/ 2004 /03
[mL.kg(-1)]
30

n.s

25

20
15

P=0.026

10

5
0
Total Volume
GEL(n=55)

Blood Loss
HES(n=55)

No better plasma expansion

effect with HES
No difference in additional
volume
Total blood loss higher in
HES group resulting in:
Nine HES patients required
12 units of allogeneic blood
Two GEL patients required
3 units of allogeneic blood

In 2003 the U.S. FDA banned

HES for usage as priming
colloid in open heart
surgery
due to the risk of
uncontrolled intra- and
postoperative bleeding!

Increased chesttube drainage

Mean blood loss 40% higher
Decrease of factor VIII & vWF
Greater mortality, longer ICU stay

HES 200 and HES 130 in

Peridural Anaesthesia

HES 200 and HES 130 have

negative effects on platelet
function! (Anaest Analg 2004

Because
hemostasiological
competence is a
prerequisite
for safe neuraxial
blockade,
the decision of HES for
intra-

Dosage Limits for Synthetic

Colloids
Synthetic colloids Dose of colloid
on 1st day of
therapy

Dose of colloid
on consecutive
days of therapy

HES 450/0.7

1.2 g/kg bw and

day
1.2 g/kg bw and
day
2.0 g/kg bw and
day
1.2 g/kg bw and

0.6 g/kg bw and

day
0.6 g/kg bw and
day
2.0 g/kg bw and
day
1.2 g/kg bw and

Gelatins

day no limit

Dextran 40
Dextran 70
HES 200/0.5

Bw= bodyweight

day

no limit

Colloids and Blood

Types
A B O

Hemostatic changes in Patients Receiving HES:

The Influence of ABO Blood Group
Hureaux, C. et al. Anesth Analg 2001;92:1396-1401
HES interfere with coagulation because of their molecular structure and the amount infused.
Coagulation defects include platelet dysfunction and decrease of the VIII/von Willebrand factor complex
(VIII/vWF). The decrease was more pronounced in patients of the O blood group (n=18) compared to the
Non-O group (n=22).

Conclusion: Intraoperative use of 6% HES 200 should be restricted in

patients of
the O blood group undergoing surgical procedures with a high risk for
after 20ml HES Infusion
nonbleeding.
O
O group
Pre-operative Period
200

200

150

150

(%)

100

100

50

50

0
VIII C

vWF

vWFRCo

VIII C

vWF

vWFRCo

7 patients who received 30 ml/kg HES had blood loss of more than 1000
ml on the 1st postoperative day. Six of those were of the O blood group!

Colloids and Blood

Saving

Boralessa,H. et al.:Effectiveness of a protocol to improve transfusion practice in knee

replacement surgery
National
Blood Service, UK, University College London, UK, Vox Sanguinis (2001)81, 248Algorithm for the administration of red blood cells and colloids during the first 24 hours intra-/postoperatively
53
Preoperative Hb value (g/L)
> 130

129-110

< 109

Gelatine (MFG) 1-1.5 times the volume

Blood loss > 1200 mL
Blood loss > 1000 mL
Blood loss > 1500
lost!
mL
Ye
s

No

a
No signs *
Continue
MFG

b
Signs *

MFG only

Is MFG effective?
Is hypovoleamia corrected?
c
Yes
Give red cells

No
Give MFG

Follow c
Reassess

Yes
Follow a

No
Follow b

Yes

No

Follow a

Follow b

Study design: Prospective observational study in 101

patients undergoing elective total knee replacement
Methods:
-The algorithm used the pre-operative Hbg level
-up to 1500 ml blood loss :replacement by MFG - effect
assessment: a heart rate of <100 beats/min and a SBP
of > 100 mm Hg.
-persistent hypotension and tachycardia after infusion
indicates anemia and PRC should be transfused.

Allogenic blood transfusions

reduced by more than 50%!

Colloids as
Priming Solutions

Priming in cardiopulmonary bypass (CPB)

MFG versus crystalloid
Effect on colloidosmotic pressure (COP)
Setting

COP

(mm Hg)

- Priming of oxygenator and

extracorporeal circuit with
1650 ml of priming solution

20

15

- CPB operation in 10
patients
per group

10

MFG

Crystalloid
CPB

0
-5

20
(min)

45

end

IC
U

P. G. M. Jansen et al., Br. J. Anaesth. 76 (1996) 1319

p < 0.05

Priming in cardiopulmonary bypass (CPB)

MFG versus crystalloid: Effect on fluid
balance
Jansen,P.G.M.

CPB
8
7
6
5
4
3
2
1
0

OR
P=0.03
P=0.03

P=0.01
P=<0.001

fluid in

balance

fluid in

Crystalloid

diuresis

MFG

blood loss

balance

Priming in cardiopulmonary bypass (CPB)

MFG versus crystalloid: Effect on
hospitalisation
10
10

Number of patients
Setting

9
p = 0.016
between groups

6
5

4
3

- Priming of oxygenator
and
extracorporeal circuit with
1650 ml of priming
solution
- CPB operation in 10
patients
per group

2
1
0

MFG
1

(days)

P. G. M. Jansen et al., Br. J. Anaesth. 76 (1996)

13-19

Crystalloid

Priming in cardiopulmonary bypass

(CPB)
MFG versus Polygeline
Effect on pH
7.46

pH

7.44

Setting:
- Priming of oxygenator and
extracorporeal circuit with
2200 ml of different gelatins.
- CPB operation in 35
patients
per group.

7.42
7.40
7.38
7.36

Modified Fluid Gelatin (MFG)

Polygeline
p < 0.05

7.34
Hypothermic (30C) CPB

7.32
pra
e

15

30

45 60
(min
)

75

90

ICU

D. Himpe et al., J. Cardiothorac. Vasc. Anaesth. 51 (1991) 457466

Priming of cardiopulmonary bypass (CPB)

with MFG , Polygeline and Albumin:
Influence on Colloid osmotic pressure (COP) and
additional fluid demand
D. Himpe et al., J. Cardiothorac. Vasc. Anaesth. 51 (1991) 457-466

(ml)
800

Additional Fluid

COP (mmHg)
25

714

23
600
472

21

400

200

19
168

14

17
15

Albumin

Polygeline

Modified
Fluid
Gelatin

Priming in cardiopulmonary bypass (CPB)

MFG versus polygeline
Bicarbonate and additional priming
(n)

HCO3boluses

15

13

(ml)

Additional
priming

800

714

- CPB operation in 35 patients

per group and additional
priming as required.
- HCO3- boluses as required to
maintain BE > - 5 mmol/l.

600

10

Setting:

400
5
200

168

1
0

0
p < 0.05

p < 0.05

Modified Fluid
Gelatin
Polygeline

D. Himpe et al., J. Cardiothorac. Vasc. Anaesth. 51 (1991) 457466

Protective effects of plasma replacement fluids on

erythrocytes exposed to mechanical stress
Sumpelmann, R. et al. Medizinische Hochschule Hannover, Anaesthesia, 2000, 55, pp: 976-979
65 ml blood samples mixed with 130ml of 4% MFG, 4% Albumin, 6% HES or Normal Saline..
Roller pump from heart-lung-maschine, circulation for 120 min. Microscopy: normal biconcave cells
in GEL and ALB groups, irregularly contoured cells in HES and spherical cells in NaCl group.

Free Haemoglobin after 120 min

of roller pump circulation
(mg/l) Before

Gelatine

After

PPS
Albumin

1200

4% MFG

1000

4% Albumin

800
600

6% HES
70/0.5
N. Saline

400

HES
HES

NaCl
NaCl

200
0

baseline
Haemoglobin

study end

630x
630x

Microscopic
Microscopic morphology
morphology of
of erythrocytes
erythrocytes

Conclusion: Modified Fluid Gelatin has a strong erythrocyte

protective effect similar to that of albumin.

British Journal of Dermatology 1997; 136: 553-559

Metze, D. et al.: Persistent pruritus after hydroxyethyl starch infusion therapy:
a result of long-term storage in cutaneous nerves

Cytoplasma of a histiocyte. Strong reactivity for HES

(arrowheads) and in the amorphous material (arrows).
Immunogold technique, x 12.600.

British Journal of Dermatology 1997; 136: 553-559

Metze, D. et al.: Persistent pruritus after hydroxyethyl starch infusion therapy: a result of
long-term storage in cutaneous nerves

M
R
A

!
S
S
LE
E

M
U
Periphereal nerve, endoneural cell (E) of a myelinated nerve fibre (M). Insert: amorphous material
(arrowhead),
myelinated axon (m), Unmyelinated nerve fibre (U). (Immunogold Technique; x9100)

British Journal of Dermatology 1997; 136: 553-559

Metze, D. et al.: Persistent pruritus after hydroxyethyl starch infusion therapy:
a result of long-term storage in cutaneous nerves

M
R
A

!
S
S
LE

Large vacuoles in histiocytes (H), endothelial cells (E) and in small

nerves (N)
12 month (!) after HES infusion. (semithin section, toluidine blue; x400)

What is not
harmless ?

Colloids
and
Hepatic Function

Liver function
Worsening of hepatic dysfunction as a consequence of
repeated
Hydroxyethylstarch infusions
Christidis, Ch. Et al.
9

Journal of Hepatology 35 (2001) 726-732

n=9

refractory ascites

cirrhosis

hepat. Granulomat.

anict.cholestasis

chron. Hepatitis

necr. Vasculitis

5
4

chron.ren.failure
repeat.HES inf.
l.vol.paracentesis

hemodialysis

death (2years)

hepat. Failure

plasma exchange

death(4weeks)

sept.shock

0
In conclusion: Repeated infusions of HES may induce massive storage in the
liver and macrophages. This accumulation may have life-threatening
consequences,
such as severe portal hypertension or liver failure!

What colloid to
use if the patient
has renal- or liver
dysfunction?

Results:
Conclusion:
Terlipressin and
Gelatine (MFG)
appear to be a safe and
effective treatment of
hepatorenal syndrome.

Colloids
in Severe Sepsis
and
Capillary Leakage

Hydroxyethyl starch and Modified Fluid Gelatin

maintain plasma volume in a porcine model of
septic shock with capillary leakage
Marx G. et al. Intensive Care Med (2002)28:629-635
MFG 4%, HES 200/0.5 6%, Ringer solution, target CVP: 12mmHg
PV=Plasma Volume, AER= Albumin Escape Rate
Baseline= before, after= 8 hours after induction of sepsis
Radio labelled erythrocytes and albumin to measure PV and AER

(%) 120
100

Non Sepsis
Sepsis

Non Sepsis
Sepsis

80
60
40
20
0
PV baselinePVafter 8 hours AER baseline after 8 hours

PV=Plasma volumeMFG 4%

HES 6%

Ringer

AER= Albumin Escape

Molnar,Z. et al.:
Fluid resuscitation with colloids of different molecular weight in
septic shock
Intensive Care Medicine; VOL.: 30 (7); p. 1356-1360/2004
(ml/m2)

Prospective randomized clinical study

including 30 septic, hypovolemic
patients with acute lung injury (ALI)
Intrathoracic blood volume index
(ITBVI) <850ml/m2
4% GEL group n=15; 6% HES 200/0.6
group n=15
Endpoint: ITBVI >900ml/m2
Boluses of each 250ml/15min,
max.1000ml

30
25
20
15
10

Conclusion: ITBVI, cardiac index, DO2

increased
significantly in both groups at t30 min and t60
min
without increasing Extra Vascular Lung Water

(ml/kg)

(n.s.)

(ml/kg)

(n.s.)

(n.s.)

5
0

increase of
ITBVI/100ml

EVLW(baseline)

HES

EVLW (t60)

GEL

Antioxidant Potential of i.v. Fluids

Stratford N, University of Bristol
Br J Anaesth 1997 Jun; 78(6):757-9
mmol/litre

1.5
1
0.5
0
Gelofusine
Aprotinin
Mannitol

FFP
4.5% Albumin
HES

Goal-directed Intraoperative Fluid Administration Reduces

Length of Hospital Stay after Major Surgery
Tang J. Gan et al. Duke University Medical Center, Durham, North Carolina, USA
Anesthesiology 2002; 97: 820 - 6
Prospective, randomized, controlled clinical trial, N=100
Methods:
control n=50 received standard intraoperative fluid therapy
protocol group n=50 received intraoperative plasma volume expansion
guided by esophageal Doppler monitor to maintain maximal stroke volume

Results:
Significantly higher stroke volume and cardiac output compared to control.
Patients of protocol group had a significantly shorter duration of hospital
stay: 5+-3 versus 7+-3 days (mean +-SD).

Conclusion:
Goal-directed intraoperative fluid administration incl. colloids results in
earlier return to bowel function, less postoperative nausea and vomiting,
and shorter postoperative hospital stay

Early Goal Directed

Fluid Therapy in
Sepsis

Hypovolaemic
shock
Cause of 85% of all shock
Most easily treated
Difficult to measure effectiveness of
treatment as it results in a non-event (i.e.
the prevention of multiple organ failure &
death)
Important to treat the hypovolaemic
component of complex shocks first
before moving on to more complex
treatments

Rivers E.: Early goal-directed therapy in

the treatment of severe sepsis and
septic shock NEJM 2001; 345:13681379

An urban Emergency Department

263 patients
Severe sepsis or septic shock
Therapy for 6 hours before transfer to ICU
Standard therapy (N=133)
Therapy guided by ScvO2 catheter (N=130)

Mortality reduced from 46.5% to

30.5%!

Rivers E.: Early Goal-Directed

Therapy In The Treatment Of
Severe Sepsis And Septic
Shock
Algorithm for Study Group
NEJM 2001;345:1368

Early Goal-Directed Therapy

(EGDT)
Rivers,E. et al., N Eng J Med 2001.345:1368-77

Fluids infused during the first 72 hours

Treatment

Hours After Start of Therapy

0-6
7-72
0-72

Total Fluid (ml)

Standard Therapy
EGDT
P value

3,499 +- 2438
4,981 +-2,984
<0.001

10,602+-6,216
8,625+-5,162
0.01

13,358+-7,729
13,443+-6,390
0.73

Which Colloid?

Standard Therapy:
(N=133)
Liver disease:
23.5%
Renal insufficiency:
21.9%

EGDT:
(N=130)
23.1%
21.4%

Rivers E.: Early Goal-Directed

Therapy In The Treatment Of Severe
Sepsis And Septic Shock
NEJM 2001; 345:1372

American Thoracic Society Consensus

Statement
Evidence-based Colloid Use in the Critically Ill:
Am J Respir Crit Care Med Vol 170.pp 1247-1259, 2004

Conclusions:

More clinical trials are needed in the field of:

-specific colloids and vascular permeability/ systemic
inflammation,
-colloids and mortality in septic and or hemorrhagic shock,
-HES and bleeding complications in cardiopulmonary
bypass surgery,
-colloids vers. crystalloids effects on outcome in patients
with ARDS
.. Gelatins may increase mesenteric blood flow

Asfar, P. et al.: Assessment of hemodynamic and gastric

mucosal acidosis with modified fluid gelatin versus 6%
hydroxyethylstarch
Intensive Care Med 2000;26:1282-1287

Results:
200

MFG has hemodynamic effects like HES

but better effects on microcirculation!

7.4

pHi

7.3
MFG
HES 200/0.62

7.2

7.1

The measurement of
intramucosal pH (pHi)
has been validated as a
prognostic index and
as a therapeutic index
of splanchnic area
oxygenation in
critically ill patients.

1
h
po
st

e
lin
se
ba

Synthetic Colloids:
Incidence of Adverse Drug
Reactions!

Incidence of anaphylaxis after infusion of

PVR solutions: Gelatin
Modified fluid
gelatin (MFG)
Tradename
Number of units/
patients
Total Incidence
(%)

Polygeline

Gelofusine

Gelafundi 2
n

Haemaccel

Haemaccel

Haemaccel

120,531
U, r

6,028
U, p

352
P, p

6,151
U, p

1,334
U, p

0.075

0.066

0.852

0.146

0.675

Incidence of reactions related to number of units infused (U) or patients

treated
(P)
(p=prospective
study, r=retrospective study)
1 Lundsgaard-Hansen Et Tschirren, Develop. biol. Standard. 48 (1981)
251-6
2 Ring Et Messmer, Lancet l (1977)
3 Laxenaire et al., Ann Fr Anesth Reanim 13 (1994) 30110
4 Weis, Anaesthesist 32 (1983) 488-93

Incidence of anaphylaxis after infusion of

PVR solutions: HES and human albumin
HES 450/0.7 HES 200/0.6 +
various solutions

Brandname

Plasmasteril
(Hespan)

Number of units/
patients*
Total
Incidence

(%)

..
Elohast
(Elohes2)

Human
albumin
1

5%

4%

16,405
U, p

4,271
P, p

60,048
U, p

2,381
P, p

0.085

0.047

0.012

0.129

*Incidence of reactions related to number of units infused (U) or patients treated

p=prospective
(P).
study, r=retrospective
study
1 Ring & Messmer, Lancet l (1977) 466-9

2 Laxenaire et al., Ann Fr Reanim 13 (1994) 302-10

Incidence of anaphylaxis after infusion of

PVR solutions: dextrans
Dextran 40
Brandname
Number of units/
patients*

Dextran 60

Dextran
70/75

RheoPlasma- Hemodex Various

solutions
macrodex cair
51,261
U, p

Total Incidence (%)

0.08

816
P, p

350
P, p

35,621
U, p
0.069

*Incidence of reactions related to number of units infused (U) or patients (P).p=prospective study, r=retrospective study
Ring & Messmer, Lancet l (1977) 466-9

Laxenaire et al., Ann Fr Reanim 13 (1994) 301-10

Adverse Drug Reactions

Early and late histamine release induced by Albumin,
HES and Polygeline: Some unexpected findings
Celik, I. et al. Inflamm. Res. 52 (2003) 408- 616
Incidence of early and late histamine release

Group

Albumin (n=6)
HES (n=6)
Polygeline n=9

Early Histamine
release<+ 10 min
1/6 = 16.7
2/6 =33.3%

3/9 = 33.3%

Early histamine
release<=30 min
3/6 = 50 %
3/6 = 50%

7/9 = 77.8%

Late histamine
release>30 min
5/6 = 83.3%
4/6 = 66.7%

7/9 = 77.8%

Overall
incidence until
240 min
6/6 = 100%
6/6 = 100%

9/9 = 100%

Conclusion: Histamine release as a novel finding for

HES should make clinicians aware of late side
effects
not yet connected with the clinical use of that
colloid!

Simple solutions to Complex

Problems
If the blood pressure goes down, give fluids
(crystalloids + colloids)
If fluids are not immediately effective, give Dopamin
If urine output decreases, give diuretics (Lasix)
If peripheral resistance is high, give vasodilators
If respiratory problems, keep the patient on the dry
side
Keep the wedge pressure less than 10-12 mmHg
If acidosis, correct with NaHCO3
If peripheral edema, give Lasix

Colloids and
pediatric indications

There is no synthetic colloid

registered and approved
especially for pediatric
indications
The decision on using synthetic colloids in pediatric
indications has to be made considering risks and
benefits on a case to case basis.
Small molecular weight colloids seem to be more
suitable.

Paediatr Crit Care Med 2004 Vol.5, No.2:

evidence is far from proving the safety of HES in neonates

After HES 57% less urine output

..tissue storage up to several years
Increased bleeding after cardiac surgery

Colloids and
Emergency Medicine

Emergency Fluid Resuscitation Strategy

(based in part on the U.S. Advanced Trauma Life Support/ adapted and modified by various
Emergency Organizations in Europe, Middle East and Asia/Pacific)

Influencing Factors: Availability / Training of medical personal

Basic Strategy:

Limitation of medical equipment/ambulances

Transportation of casualities
Variable transportation time
Emergency physician/paramedics + ambulance
as close as possible to the accident/road side

Minimize evacuation time

Emergency Fluid Resuscitation Strategy

Scoop and run or Stay and stabilize?

Goal: Early rapid evacuation of casualities to a surgical unit!

Casuality
(Securing airway and breathing)
Rescue Time
Less than 1 hour

Fluid resuscitation during transport

Controlled hemorrhage

More than 1 hour

Resuscitation before evacuation

Controlled hemorrhage

Uncontrolled hemorrhage
(hypotension,vasoconstriction,thrombus formation)

Crystalloids +
Colloid

Crystalloids + Colloids
Gelatine or HES solution)

HOSPITAL

Aggressive fluid therapy

prohibited!
Hypotensive
resuscitation

E. Rudolph 2004

Conclusions
!. Emergency physicians, trained paramedics and ambulances as close as possible to
the road side to minimize evacuation time (helicopters)
2. In controlled hemorrhagic shock normalize hemodynamics with fluid infusion
3. In uncontrolled hemorrhage no aggressive fluid therapy (risk of re-bleeding,
hemodynamic decompensation and increased mortality)
4. If estimated evacuation time < 1 hour immediate evacuation after airway and
breathing is secured, i.v. infusions on the way to surgical unit (scoop and run)
5. If estimated evacuation time is > 1 hour, crystalloids + colloids, but limited infusion
rate in uncontrolled hemorrhagic shock (risk of re-bleeding) hypotensive
resuscitation
6.

During evacuation Gelatin solutions seem to be very suitable : lack of coagulation

disorders, low risk of circulatory overloading and therefore easy to handle by
paramedics!

Summary
and Clinical
Consequenc
es:

Effects of Synthetic Colloids

Keep the fluid
in the IVS

Oncotic
pressure

Increased IV
volume

Hemodilution

Venous flow-back
(preload)

Improved
rheology

Hematocrit

Cardiac
output

Flow
resistance

Arterial oxygen
concentration

CO

DO
2

ca O2

HES 130/0.4: same complication risks as HES 200/0.5!

Both impair renal function

.Both coagulopathy and clinical

bleeding after HES 200 and HES 130

Simple
Solutions?

Simple solutions to Complex

Problems

If the blood pressure goes down, give fluids

(crystalloids + colloids)
If fluids are not immediately effective, give Dopamin
If urine output decreases, give diuretics (Lasix)
If peripheral resistance is high, give vasodilators
If respiratory problems, keep the patient on the dry
side
Keep the wedge pressure less than 10-12 mmHg
If acidosis, correct with NaHCO3
If peripheral edema, give Lasix

Demands on Synthetic
Colloids:

9 inexpensive and free of infectious agents

9 available in unlimited quantities
9 stable for long periods of time
9 colloid osmotic pressure and viscosity like
plasma
9 completely degradable and eliminated via
kidneys
9 no longtime storage in the organs
9 sufficient volume effect and duration
9 free of coagulation disorders

The excellent pharmacological and safety

profile of
Modified Fluid Synthetic Gelatin
Strong volume effect with only 4% concentration
Similar COP and viscosity like plasma
Moderate duration of up to 4 hours
No risk of overloading
Protecting effect on erythrocytes
No increased risk of coagulation disorders
No blockage of thrombocytes
No negative impact on renal function
No negative impact on liver function
No interference with blood groups
Suitable also in severe sepsis and septic shock
No RES storage/ no blockage of immune function
No late histamine release

For the selection of the right colloid for the

right indication the following points need to
be considered:

Amount of blood loss

Amount of plasma/fluid

loss
Renal function
Liver function
Coagulation status
Immune function
Age of patient
Kind of injury
Kind of procedure

Kind of colloid
Molecular Weight
Initial Volume
effect
Duration of effect
Documented
allergies
Indications
Contraindications
Precautions

The decision on what synthetic

colloid should be selected has
to be
made considering the pro and
cons of each specific solution
and the
specific conditions of each
individual patient on a
case to case basis!

Blood
loss
(%)

Replacement of blood losses

Step by step

100
90
80
70
60
50
40
30
20
10

Colloids + +crystalloids
PRC
Cryst.+colloids

+FFP

+platelets

Target controlled replacement of

volume - oxygen carriers - plasmatic coagulation - cellular coagulation
Adapted from Adams, H.A.
1996

Synthetic Colloids for Different

Indications
(not every colloid is indicated for every indication)

Hemorrhagic shock

GEL/HES/DEX (Dose!)

General/
Cardiac Surgery

GEL
HES + DEX dose limit!!!

Priming of HLM
Therapy during Hemodialysis

GEL

ICU/Severe Sepsis/
Burns

Oliguria?
DIC?

NO
YES

GEL/HES/DEX
GEL

Hepatic Dysfunction/
Liver Transplantation?

GEL
HES contraindicated!

Renal Dysfunction/
Kidney Transplantation?

GEL
HES contraindicated!

Heat Stroke

GEL

Neurosurgery/
Intracerebral Vasospasm

GEL/
HES dose limit!

Acute Ischemic Cerebral stroke

GEL/HES Dose limit!

Arterial/Venous Obstructive
Disease (Eye/Ear)

HES/GEL

Peridural anaesthesia in pain

patients

GEL

Modified Fluid Gelatin

(MFG)
is effective, clinically well
documented and has an
excellent safety profile!

Medical University
Muenster, Germany