The Appropriate Role of Colloids in Managing Fluid Imbalance: a Critical Review of Recent Meta-analytic Findings

Three meta-analyses have recently been reported on the relationship between choice of resuscitation fluid and risk of mortality in critically ill patients. The relative risk of death (1.16-1.19) in two of the meta-analyses was slightly higher in colloid than crystalloid recipients; however, this observation was not statistically significant. In the third meta-analysis, 6% (95% confidence interval [CI], 3-9%) pooled excess mortality was documented in patients receiving albumin for hypovolaemia, burns or hypoalbuminaemia. The mortality difference in hypovolaemia patients (4%; 95% CI, 0-8%) was not statistically significant. A variety of serious limitations apply to the three meta-analyses, suggesting that their findings be interpreted cautiously. More than one-half of the randomized controlled trials (RCTs) included in the meta-analyses were reported prior to 1990 and hence do not reflect current practice. Each meta-analysis included only a subset of relevant RCTs, and therefore the scope of inferences to be drawn from the meta-analytic results is limited. The meta-analyses combined RCTs that were notably heterogeneous with respect to patient characteristics, type of illness, administered fluids and physiologic endpoints. Differences in illness severity, concomitant therapies and fluid management approaches were not taken into account. Very few of the RCTs were blinded. The meta-analyses do not support the conclusion that choice of resuscitation fluid is a major determinant of mortality in critically ill patients, nor do they support changes to current fluid management practice. Changes such as exclusive reliance on crystalloids would necessitate a reassessment of the goals and methods of fluid therapy. Since the effect on mortality may be minimal or non-existent, choice of resuscitation fluid should rest on whether the particular fluid permits the intensive care unit to provide better patient care.