Efficacy and Safety of Colloids Versus Crystalloids for Fluid Resuscitation in Critically Ill Patients
|First Received Date ICMJE||September 2, 2005|
|Last Updated Date||June 29, 2014|
|Start Date ICMJE||February 2003|
|Primary Completion Date||August 2012 (final data collection date for primary outcome measure)|
|Current Primary Outcome Measures ICMJE
||28-day mortality [ Time Frame: Day 28 ] [ Designated as safety issue: Yes ]|
|Original Primary Outcome Measures ICMJE
|Change History||Complete list of historical versions of study NCT00318942 on ClinicalTrials.gov Archive Site|
|Current Secondary Outcome Measures ICMJE
|Original Secondary Outcome Measures ICMJE
|Current Other Outcome Measures ICMJE||Not Provided|
|Original Other Outcome Measures ICMJE||Not Provided|
|Brief Title ICMJE||Efficacy and Safety of Colloids Versus Crystalloids for Fluid Resuscitation in Critically Ill Patients|
|Official Title ICMJE||CRISTAL: Colloids Compared to Crystalloids in Fluid Resuscitation of Critically Ill Patients: A Multinational Randomised Controlled Trial|
Background: Two recent systematic reviews of the literature and meta-analyses have suggested that colloids administration might be deleterious in critically ill patients.
Objective: To compare the effects on hospital mortality of crystalloids and colloids when given for fluid resuscitation in critically ill patients.
Setting: Adult intensive care units (ICUs) in several European countries.
Study design: A multinational, randomised, controlled trial performed on two parallel groups.
Intervention: Any type of crystalloids (control group) versus any type of colloids (including albumin).
Patients: All patients above the legal age of consent and hospitalised in an intensive care unit, who need fluid resuscitation (according to the physician). Pregnant women, moribund patients, brain dead patients, and patients who have a known allergy to colloids or severe head injury or major burns (> 20% of body surface) or dehydration will not be included.
Primary endpoint: 28-day mortality.
Hypothesis: Assuming a hospital mortality rate of 20% in the crystalloids group, a 0.05 type I error, 3010 patients are needed to show a difference between the 2 groups of 5% with a 90% probability (two-sided test).
Fluid resuscitation is a very common treatment in the ICU, and every day a thousands of critically ill patients are treated around the world with crystalloids or colloids to correct hypovolaemia (1, 2). A wide diversity of fluids is available, and new products are coming in the very near future. In 1989, a French consensus conference recommended to abandon the use of fresh frozen plasma and to limit the use of albumin to very specific situations (e.g. contraindication to other colloids, serum protein levels below 35 g/l) (1). Crystalloids and gelatins were considered as the best solutions for fluid resuscitation in the critically ill. In 1997, as starch was increasingly used, this guidelines were updated (2). It was concluded that isotonic crystalloids are as efficacious as starch pending the amount of fluid to be administered.
Three systematic reviews of the literature provided an accurate summary of data available from randomised controlled trials evaluating human albumin (3), or comparing crystalloids to colloids in fluid resuscitation in critically ill patients (4,5). The first systematic review (3) has analysed 30 randomised trials and concluded that there is no evidence that albumin administration reduces the risk of death in critically ill patients. By contrast, this review suggested that albumin administration might increase by 6% the risk of death. In the Cochrane Injury Review Group systematic review (4), 40 randomised trials were analysed. The authors concluded that the administration of colloids might be associated with an absolute increase of 3.8% in the risk of death. The last review has analysed only 17 randomised trials as they decided to exclude studies of hypertonic saline. This review showed no significant difference in the risk of death between colloids and crystalloids or in other outcomes like prevalence of pulmonary edema and length of stay at the ICU and at the hospital (5). However, when the authors considered only the studies with a high methodological quality score, they observed a nice trend toward an increased survival rate in favour of crystalloids. They reached the same conclusions for the subset of trauma patients.
JUSTIFICATION FOR THE STUDY
It seems reasonable to abandon the use of fresh frozen plasma in fluid resuscitation in critically ill patients. There are no definite criteria to decide which of crystalloids and colloids should be preferred. It is unquestionable that, to achieve a given haemodynamic effect, the amount of crystalloids needed is almost twice the amount of colloids (1, 2). Colloids and crystalloids have different effects on a range of important physiological parameters. As most of the critically ill patients underwent one or more volume replacements, even a small increase in the risk of death (around 5%) has considerable clinical implications. The meta analyses suggested a 5% absolute risk reduction in mortality in favour of crystalloids (4, 5). The number needed to treat, an estimate which is more clinically meaningful (6), is of 20, suggesting about 1 additional death (with colloids) for every 20 patients resuscitated. Given the number of patients exposed to fluid resuscitation, about 60 additional deaths might be observed per year in a ICU,receiving 600 patients a year.
A large trial is needed to compare the safety and efficacy of colloids and crystalloids (4,5).
To compare the effects on 28-day mortality of colloids versus crystalloids in ICU patients who need fluid resuscitation.
ICU and hospital mortality and morbidity, and safety.
A multinational, randomised, controlled trial, on two parallel groups.
Double blind seems unfeasible as the time window for inclusion is extremely short (treatment should be available promptly at bedside) and the amounts of volume replacement for all ICU stay could not be predicted a priori.
Co-interventions not allowed:
Any other volume replacement solution than those above mentioned. Albumin is not allowed in patients allocated to crystalloids unless plasma albumin levels are below 20 g/dl (2).
The list of randomisation will be generated by computer. We will use block randomisation stratified by site and diagnosis,
From H0 (time of randomisation) to H24:
Daily from Day-1 to ICU discharge:
At ICU discharge:
At hospital discharge (if not the same as that of ICU discharge):
This study is designed to show an absolute difference of 5% in 28-day mortality between colloids and crystalloids. Assuming a mortality rate of 20% in the crystalloids group, with alpha = 5% and beta = 10%, 1504 patients per treatment arm are needed. A total of 3010 patients will be enrolled. All randomised patients must be followed up (at least) till ICU discharge. One hundred active centres will be recruited in Europe. The participation of each centre will be around 3 to 6 months.
Interim analyses and stopping rules
The boundaries of the sequential plan are drawn to demonstrate an absolute difference of 5% in 28-day mortality rate between the two treatment arms, assuming a 20% mortality rate in the crystalloids group, and with alpha and beta of 5% and 10% respectively. The analyses will be performed every 100 deaths. The figure displays the boundaries of the sequential plan. Briefly, Z represents the difference between the two groups and V the number of patients that have been included. When a boundary is crossed, the enrollments in the study must be stopped, and the conclusion depends on which boundary has been crossed (see figure). Simulations allow to estimate how many inclusions are saved: when difference in mortality rates is nil, 1109 patients have to be included to reach the conclusion. When difference is 5%, 1477 patients have to be included to reach the conclusion.
The final analysis will be performed according to the intention to treat principle, after inclusions in the study will be stopped.
Baseline characteristics of patients will be compared between the two treatment arms: categorical variables will be expressed as number and percentage and compared by Chi-2 tests, means, standard deviation, and range will be given for continuous variables, which will be compared by Student t tests.
Methods for analyses of efficacy and safety will depend on the type of outcome. Survival curves will be constructed according to the Kaplan-Meyer method, and compared by log-rank tests. The comparison will be adjusted the main prognosis variables with Cox models. Categorical variables will be compared by Chi-2 tests, and continuous variables Student t tests or analysis of variance for repeated measures.
PI: Djillali Annane (Garches), Statistician: Sylvie Chevret (Paris) Yves Cohen (Avicenne), Samir Jaber (Montpellier), Gilles Troché (Versailles) Fékri Abroug (Monastir, Tunisie) Olivier Lesur (Sherbrook, Canada),
Jean François Baron, François Feihl (Lausanne, Suisse), Jean Louis Vincent (Bruxelles, Belgique)
Safety and Efficacy Monitoring Board:
Edward Abraham (Birmingham, USA), Déborah Cook (Hamilton, Canada), Mervyn Singer (London, UK), Charles Sprung (Jérusalem, Israel)
|Study Type ICMJE||Interventional|
|Study Phase||Phase 3|
|Study Design ICMJE||Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Single Blind (Outcomes Assessor)
Primary Purpose: Treatment
|Condition ICMJE||Critical Illness|
|Study Arm (s)||
|Publications *||Annane D, Siami S, Jaber S, Martin C, Elatrous S, Declère AD, Preiser JC, Outin H, Troché G, Charpentier C, Trouillet JL, Kimmoun A, Forceville X, Darmon M, Lesur O, Régnier J, Abroug F, Berger P, Clec'h C, Cousson J, Thibault L, Chevret S; CRISTAL Investigators. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013 Nov 6;310(17):1809-17. doi: 10.1001/jama.2013.280502.|
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Recruitment Status ICMJE||Completed|
|Completion Date||November 2012|
|Primary Completion Date||August 2012 (final data collection date for primary outcome measure)|
|Eligibility Criteria ICMJE||
Patients who have one or more of the following items:
|Ages||18 Years and older|
|Accepts Healthy Volunteers||No|
|Contacts ICMJE||Contact information is only displayed when the study is recruiting subjects|
|Location Countries ICMJE||Belgium, Canada, France, Tunisia, United Kingdom|
|NCT Number ICMJE||NCT00318942|
|Other Study ID Numbers ICMJE||AOM01020, P010308|
|Has Data Monitoring Committee||Yes|
|Responsible Party||Djillali Annane, University of Versailles|
|Study Sponsor ICMJE||University of Versailles|
|Collaborators ICMJE||Assistance Publique - Hôpitaux de Paris|
|Information Provided By||University of Versailles|
|Verification Date||June 2014|
ICMJE Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP