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Fluid replacement after major cardiac and vascular surgery - no difference in pulmonary oedema formation using saline or colloid.

 

Provided that fluid overloading is avoided, the type of fluid used for volume replacement after cardiac and major vascular surgery does not affect pulmonary permeability and oedema formation.  

Level of Evidence: 1- (RCT with a high risk of bias)

 

Citation/s: Effect of fluid loading with saline or colloids on pulmonary permeability, oedema and lung injury score after cardiac and major vascular surgery. Br J Anaesth 2006; 96 (1):21-30
 

Lead author's name and fax: J. Verheij johan.groeneveld@vumc.nl

 

Three-part Clinical Question:

Patients: hypovolaemic patients who have undergone cardiac or major vascular surgery.  Treatment: saline or colloid; Outcomes: development of pulmonary oedema, increased pulmonary permeability and increased Lung Injury Score (LIS)

Search Terms: (PubMed) pulmonary oedema after major surgery (no limits)

 

The Study: Single-blinded, randomised  trial without intention-to-treat.

The Study Patients: Mechanically ventilated, hypovolaemic on admission to ICU, following cardiac or major vascular surgery, stratified into cardiac (n=40) or major vascular surgery (n=28).  Hypovolaemia defined as systolic blood pressure <110mmHg and either a PCWP </= 10mmHg or a CVP </=8mmHg.Once diagnosed as hypovolaemic, all patients were managed in a similar manner except for the type of fluid used in the fluid challenge protocol: Fluid loading with target central venous pressure of 13mmHg and pulmonary capillary wedge pressure of 15mmHg was performed for 90minutes. Cardiac output, intrathoracic blood volume, extravascular lung water (EVLW), pulmonary permeability and lung injury score were calculated.

 

Control group (N = 16; 16 analysed): 0.9% normal saline as per protocol.

 

Experimental group (N = 52; 51 analysed): Colloid group. Gelatin 4% (N=16), HES 6% (N=17) or albumin 5% (N=18) as per protocol.

 

The Evidence:

 

Variable

Crystalloid

Colloid

p-value

Crystalloid vs Colloid

 

Cardiac Index

Mean increased by 3.3%

Mean increased by 26%

<0.005

Colloid oncotic pressure

Decreased

Increased

<0.001

Pulmonay Leak Index

No Change

No Change

NS

Extravascular Lung Water

Decreased

Decreased

NS

Lung Injury Score

Unchanged

Increased

<0.001

 

 


EBM questions:

 

1.      Do the methods allow accurate testing of the hypothesis? No. The study was not investigator blinded, the control group and experimental group were markedly different in size. The experimental group was not homogeneous; made up of 3 different colloid groups. In addition, data was not available for the whole group for EVLW, being available for 14 of the saline group (87.5%), but only 40 of the colloid group (78.4%).

2.      Do the statistical tests correctly test the results to allow differentiation of statistically significant results?  Yes.

3.      Are conclusions valid, in light of the results? Yes. Provided fluid overloading is prevented, the type of fluid used for volume loading does not effect pulmonary permeability and oedema.

4.      Did results get omitted, and why? One patient was excluded because of technical failures.

5.      Did they suggest areas of further research? No.

6.      Did they make any recommendations based on the results, and were they appropriate? No.

7.      Is the study relevant to my clinical practice? Possibly. Fluid resuscitation of post-surgical patients forms a large part of Critical Care workload, and despite many studies and meta-analyses, the crystalloid-colloid controversy still exists. However many units target CI as a goal for fluid resuscitation rather that filling pressures so this study may not represent usual practice. Targeting flow may well lead different results.

8.      What level of evidence does this study represent? Level 1-.

9.      What grade of recommendation can I make on this result alone? None.

10.  What grade of recommendation can I make when this study is considered along with other available evidence? None.

11.  Should I change my practice because of these results? No.

12.  Should I audit my current practice because of these results? No.

 

 

Appraised by: Rebecca Appelboam, Department of Anaesthesia, Torbay Hospital, Torquay, Devon. TQ2 7AA; 22 January 2006
Email: rebecca.appelboam@nhs.net

 

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. 2006 & JICS 2006 Vol7(1). Appleboam R. Verheij J, et al. Effect of fluid loading with saline or colloids on pulmonary permeability, oedema and lung injury score after cardiac and major vascular surgery. Br J Anaesth 2006; 96 (1):21-30

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Kill or Update By: 1st January 2011

 

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