Another Review, Same Findings on Crystalloid vs Colloid?

Aaron B. Holley, MD


December 17, 2014


In April of this year, a randomized controlled trial (RCT) published in the New England Journal of Medicine found that albumin did not reduce mortality from severe sepsis or septic shock.[1] Having reviewed the literature up to that point, I felt that the data weren't strong enough to recommend using albumin in lieu of crystalloid solutions. (I wrote about that study earlier this year; you can read it here.) Since that time, there's been yet another review of fluid resuscitation for sepsis.

Rochwerg and colleagues[2] published a meta-analysis in the Annals of Internal Medicine earlier this year that was summarized in the most recent ACP Journal Club.[3] The review uses novel analytic methods (indirect comparisons) and specifies the electrolyte composition of the crystalloids that were evaluated, which makes it different from those published before. Although the indirect comparisons are sure to make some readers skeptical, I believe they are valid but limited (as discussed by the authors). We're unlikely to see another large RCT like the SAFE trial,[4] so indirect comparisons are a step up from (or at least a complement to) expert opinion and anecdotal experience.

Albumin: To Use or Not to Use?

What did they conclude? They found that albumin was superior to starches and that balanced crystalloids are superior to those that are unbalanced. As stated in the ACP Journal Club review and the editorial accompanying the original article,[5] the concept that balanced crystalloids would be superior has biologic plausibility but the data supporting their use remain weak.

It's not yet clear that we should abandon standard resuscitation fluids such as normal saline. Switching everyone with sepsis to lactated ringer's, the most readily available balanced solution, could have unintended consequences.

Albumin consistently reduced mortality when compared with unbalanced crystalloids, although the 95% confidence intervals for the odds ratios always crossed 1. We've seen albumin "signal" before, but in my opinion we still lack definitive data to prove they justify their cost. For now, normal saline will continue to be my default choice for resuscitation in sepsis.


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