Colloids - an overview Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute , puducherry – India Colloids • Colloids tend to be larger molecules than crystalloids • dispersed throughout the solvent rather than forming true solutions. • The component particles tend to arrange as groups of molecules and so do not readily pass through clinical semipermeable membranes. • They therefore have an oncotic potential that is usually measured as colloid osmotic pressure (COP). Image of a colloid But crystalloids !!! • Crystalloid solutions are solutions of sugar or salt or mixture of salt and sugar in water. • Crystalloids remain intravascular for short period and metabolise to carbon dioxide, water, ions and yields energy. In simple terms • Osmotic pressure • Exerted by salts to push fluid out • Oncotic pressure exerted by colloids to get fluid in the blood vessel Colloids • Colloids are solutions of high molecular weight substances that largely remain in the intravascular compartment for longer period and generate an oncotic pressure as well as slowly being metabolized. Colloids • number of molecules per volume of solution is usually lower than crystalloid solution. • No effect on osmolarity • Hence electrolytes are added. Half life • the intravascular half-life of a crystalloid solution is 20–30 min, • most colloid solutions have intravascular halflives between 3 and 6 h. Characters • General characteristics of the colloid are • (i) particles have high molecular weight, • (ii) high osmolality. and high oncotic pressure (iii) longer plasma half life • (iv) higher plasma volume expansion • 25 % Vs 125% Types of colloids • colloids are either natural or artificial. • The natural colloids are blood, human albumin and fresh frozen plasma. • Artificial colloids are dextrans, gelatins and starch. Artificial colloids are polymers containing molecules with wide range of molecular weight • Monodisperse and polydisperse Characters • Molecular weight : oncotic pressure • Osmolality and oncotic pressure: Almost all colloid solutions have a normal osmolality. The oncocity of the solution will influence the vascular expansion. • Plasma half-life: The plasma half-life of a colloid depends on its MW, the elimination route, and, the involved organ function (mainly eliminated by the renal route Characters • MW --- oncotic pressure – initial volume expansion ---- half life – persistence • The degree of volume expansion is mainly determined by the MW, whereas the intravascular persistence is also determined by the elimination of the colloid. Characters • Acid-base composition: Albumin and gelatin solutions have physiological pH, while other solutions tend to have acidic pH. • Electrolyte content: The sodium concentration is low in “salt-poor albumin Others same Human albumin solution • principal natural colloid comprising 50 to 60% of all plasma proteins • contributes to 80% of the normal oncotic pressure in health. • MW = 69,000 Dalton • Synthesis – liver Human albumin solution • 5% solution is isooncotic and leads to 80% initial volume expansion • 25% solution is hyperoncotic and leads to 200 - 400% increase in volume within 30 minutes. • The effect persists for 16 - 24 h Structure of albumin Indications: • a. Emergency treatment of shock specially due to the loss of plasma • b. Acute management of burns • c. Fluid resuscitation in intensive care • d. Clinical situations of hypo-albumineamia i. Following paracentesis ii. Patients with liver cirrhosis (For extracorporeal albumin dialysis (ECAD)) iii. After liver transplantation • e. Spontaneous bacterial peritonitis • f. Acute lung injury Advantages: • • • • • Natural Volume expansion possesses antioxidant and scavenging effects Disadvantages: Costly , ‘leakiness’ of the vascular endothelium and volume overload Dextran • highly branched polysaccharide molecules • Artificial • synthesis using the bacterial enzyme dextran sucrase from the bacterium Leuconostoc mesenteroides • 6% solution with an average molecular weight of 70,000 (dextran 70) • 10% solution with an average weight of 40,000 (dextran 40, low-molecular-weight dextran) characters • Kidneys primarily excrete dextran solutions. • Both dextran-40 and dextran-70 lead to a higher volume expansion as compared to HES and 5% albumin. (100 to 150%) • The duration lasts for 6–12 hours Dextran – slowly decreasing uses • used mainly to improve micro-circulatory flow in microsurgical re-implantations. • Extracorporeal circulation: Disadvantages • Anaphylactic reactions: • Coagulation abnormalities: • Interference with cross-match: • Precipitation of acute renal failure: Gelatins • Gelatin is the name given to the proteins formed when the connective tissues of animals are boiled • If you cool, it may gellify !! Modified gelatins • Succinylated or modified fluid gelatins (e.g., Gelofusine, Plasmagel, Plasmion) • Urea-crosslinked gelatins (e.g., Polygeline) • Oxypolygelatins (e.g., Gelifundol) • Polygeline (‘Haemaccel’, Hoechst) is produced by the action of alkali and then boiling water (thermal degradation) on collagen from cattle bones. • MW = 35000 haemaccel • . Polygeline is supplied as a 3.5% solution with electrolytes (Na+ 145, K+ 5.1, Ca++ 6.25 & Cl − 145 mmol/l). • calcium ions -- increase in serum calcium concentration following large volume resuscitation. • Polygeline also contains potassium ions: Succinated gelatin Character and indications • • • • • • Kidneys excrete 70 -80 % volume expansion 2 -3 hours Hypovolemia due to acute blood loss. Acute normovolaemic haemodilution. Extracorporeal circulation – cardiopulmonary bypass. • Volume pre-loading prior to regional anaesthesia. • ADVANTAGES AND DISADVANTAGES • Cost effective: • No limit of infusion: • No effect of renal impairment: • Higher anaphylaxis than albumin • Coagulation – platelet adhesions decreased • Increased PRA and possible circulatory problems Hydroxyethyl starches (HES) • Starch is polysaccharide carbohydrate and seen to produce less morbidity compared to dextrans or gelatins. • As a class, starch is safer than other colloid and is a near – ideal resuscitation fluid. How to get amylopectin rich corn • Amylases glucose molecules • Hydroxy ethylation • neutralised with alkali and further purified • HES Voluven HES • Concentration: low (6%) or high (10%). • Molecular Weight (MW): low ( 70 kDa), medium ( 200 kDa), or high ( 450 kDa). • • • • Polydisperse Small excreted Large fragmented to small continuous supply of oncotically active molecules • Molar substitution (MS): low (0.45–0.58) or high (0.62–0.70) • A varying number of hydroxyethyl residues attached to the anhydrous glucose particles within the polymer. • increases the solubility of the starch in water, inhibits the rate of destruction of the starch polymer by amylase. MS !! What is this ?? • The figure 0.7 in the description of a HES preparation indicates that there are seven hydroxyethyl residues on average per 10 glucose subunits.(hetastarches) • hexastarch (MS 0.6), • pentastarch (MS 0.5), • tetrastarch (MS 0.4). • C2/C6 ratio: low (<8) or high (>8). • The C2/C6 ratio refers to the site where substitution has occurred on the initial glucose molecule. • The higher the C2/C6 ratio, longer the half-life and hence, longer persistence in the blood Metabolism • initially a rapid amylase-dependent breakdown and renal excretion. • Plasma half life is 5 days and 90% is eliminated in 42 days. • Smaller HES molecules (<50,000 to 60,000 Dalton) are eliminated rapidly by glomerular filtration. • Medium sized molecules get excreted into the bile and faeces. • Another fraction - taken up by the reticuloendothelial system where the starch is slowly broken down. Detected for several weeks after administration Advantages • Volume expansion 100% • Duration 8-12 hours • • • • Shock Endotoxemia Maximal – 50 ml/kg Cost less than albumin Problems • • • • Coagulation Renal impairment Accumulation and itching Anaphylactoid reactions • But ? Found in third generation – tetrastarch !! pharmacokinetics • Clearance of the latest generation (third generation) 130/0.4) is 20 to 30 fold higher compared to first generation HES • therapeutic safety index of third generation HES (130/0.4) (C2-C6 >8) is higher compared with all other HES solutions Third-generation HES: tetrastarch v • Reductions in MW and MS have led to products with shorter half-lives, • improved pharmacokinetic • pharmacodynamic properties, • fewer side effects Benefits over older starches • reduced effect on the coagulation process compared to older products • rapid clearance of the latest generation of tetrastarches, - less accumulation • Less tissue persistence – less itching Benefits over older starches (130/0.4) • Waxy maize better over potato derived in liver dysfunction • Renal dysfunction, elderly, hepatic dysfunction ,Cardiac surgery, abdominal aortic surgery • Also children Effects on Microcirculation and Oxygenation • beneficial effects microcirculation, on organ tissue perfusion, oxygenation, inflammation, endothelial activation, capillary leakage, and tissue edema over and above their volume replacement effects • We are using them in shock states Crystalloids Vs colloids • Intravascular persistence • Volume expansion • • • • Anaphylaxis, Renal Cost Coagulation Trials • 1989 – may be more deaths with colloids • no difference in outcome among patients treated with colloids or crystalloids (BMJ – 1998) • SAFE (Saline versus Albumin Fluid Evaluation) trial • 7000 critically ill patients requiring fluid resuscitation to receive isooncotic albumin or isotonic crystalloid. • There was no overall difference in outcome The danger starts FDA recommendations – June 2013 • Do not use HES solutions in critically ill adult patients including those with sepsis, and those admitted to the ICU. • Avoid use in patients with pre-existing renal dysfunction. • Discontinue use of HES at the first sign of renal injury. • Need for renal replacement therapy has been reported up to 90 days after HES administration. • Avoid use in patients undergoing open heart surgery in association with cardiopulmonary bypass due to excess bleeding. • Discontinue use of HES at the first sign of coagulopathy. • This is an overview • Read well for more details • Are colloids – boon to gloom !! 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