Plasma Protein Fraction Human Albumin H2O Human Albumin is used to treat hypoalbuminaemia and enhancing oncotic pressure in the intravascular compartment. Concentration ranges from 3.5 to 25%; The 4-5% solution are isooncotic whereelse the 20-25% solutions are hyperoncotic. They are prepared from human blood plasma , 5% human albumin solution provide colloid oncotic pressure of 20 mmHg. 5% plasma protein Contain albumin, - globulin and Factor VIII Replacement of plasma Not a volume resuscitation product Plasma Protein Fraction

GELATINS Hypooncotic, volume effect about 70% Rapid renal elimination Gelatins are prepared by hydrolysis of animal collagen. Comes in 3 to 3.5% solution. Has a molecular weight of 30-35 kDalton. Possibility of allergic reaction to animal protein and cross linking substances. Cross linking substances include: urea, succinic acid and succinyl –coA. Gelatins are hypooncotic and the volume effect is about 70% and it is rapidly eliminated by the kidney. Hypooncotic, volume effect about 70% Rapid renal elimination

DEXTRAN ↓ MW: 10% Dextran 40 2 Types:  MW: 6% Dextran 70 Dextran 40: hyperoncotic, volume effect about 200% Dextran 70: isooncotic, volume effect about 100% Is synthesize from sucrose by leukonostoc bacteria. The resulting high MW dextran are then cleaved by acid hydrolysis and separated by repeated ethanol fractionation into a final product with restricted MW range. The high MW 6% dextran 70 is isooncotic and has a volume effect of about 100%. Low MW dextran 40 is hyperoncotic with volume effect of about 200%.

DEXTRAN ↓ Platelet adhesiveness ↓ Blood viscosity ↓ Serum fibrinogen Enhance fibrinolysis Useful for prophylaxis against Thromboembolism Dose > 1.5 g/kg  risk of bleeding Dextran decrease platelet and RBC adhesiveness and reduce blood viscosity. It also reduce serum fibrinogen and enhance fibrinolysis. It is used in microvascular surgery as well as prophylaxis against thromboembolism. Doses above 1.5Gm/kg/day can cause an increase in the risk of bleeding. Dextran administration can cause the development of antibodies in about 60-70% of the patients which can cause anaphylactic/ anaphylactoid reaction.

Derived from corn starch HYDROXYETHYL STARCH Derived from corn starch Amylopectin: a branched chain of glucose molecule Rapidly cleaved by -1,4 amylase The degradation controlled by substitution (hydroxylation) HES is derived from corn starch which comprise of 95% Amylopeptin. Amylopeptin are made of branched chain glucose molecule. These molecules are rapidly cleaved by endogenous alpha 1-4 amylase.

Crystalloids Advantages Disadvantages Balanced electrolyte compositions Poor plasma expander (3 – 4L needed to replace 1 L of blood) Buffering capacity (e.g. lactates) Large volume may produce undesired effects Examples: 0.9% NaCl may produce hyperchloremic metabolic acidosis Easy administration Reduce plasma oncotic pressure and risk of edema Less risk of adverse reactions (anaphylaxis/anaphylatoid) Risk of hypothermia Does not affect hemostasis This slide is a simplified summary of the advantages and disadvantages of using crystalloid. The main disadvantage of crystalloid during acute hypovolemic state is clearly because it is a poor plasma expander. This is because after an infusion of 1 pint of crystalloid, only approximately 20% or 100 ml stays in the plasma. Furthermore, crystalloid causes reduction in plasma oncotic pressure which would result in risk of tissue edema.

Colloids Disadvantages Risk of overload Coagulopathy Good intravascular expander Risk of overload Rapid volume expansion (resuscitation) Coagulopathy Less risk of edema (pulmonary edema and tissue edema) Risk of adverse reactions (anaphylaxis) Maintain plasma oncotic pressure Tissue accumulation in the event of capillary leak Enhance microvascular flow On the other hand, this slide demonstrate the advantages and disadvantages of colloids. Colloids has the advantages of being a good and rapid plasma expander, less risk of developing edema because it does not lower the plasma oncotic pressure and because of that, it also improves microcirculation. However, generally colloids have been associated with increased risk of coagulopathy and anaphylactoid reactions.

Properties of resuscitation fluids Crystalloid Gelatin Albumin HES Molecular Weight 60 da 30-35 kda 69kda 130-450 kda Volume Effect This is a guide to the properties of different fluids to show that ‘All colloids are not created equal’. As you have heard all hydroxyethyl starches are not the same and there has been a steady improvement in their properties moving towards a narrow range molecular weight between 100 to 200 kilo Daltons, short plasma life and complete renal excretion. 10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs