Report by

Minesh Khashu, Lead Neonatologist, Poole Hospital NHS Trust, Poole, Dorset, UK; mineshkhashu{at}gmail.com

Velur Balasubramaniam, Neonatal Unit, Leicester Royal Infirmary, Leicester LE1 5WW, UK

A neonate born at 26 weeks and weighing 930 g underwent laparotomy on day 21 of life for perforation secondary to necrotising enterocolitis (NEC). He required fluid resuscitation during the procedure and Gelofusine was given rather than normal saline or blood products. We reviewed the evidence for the use of Gelofusine for volume replacement in neonates.

Structured clinical question

In neonates requiring intravascular volume replacement/resuscitation [patient] is use of Gelofusine [intervention] efficacious and safe [outcome]?

Search strategy and outcome

Search terms: “Gelofusine”, “Gelatin” and “Synthetic Colloids”.

Search literature: PubMed and Medline 1966–2005, EMBASE 1974–2005, Cinahl 1982–2005 using Dialog Data Star, Google Scholar, Proquest journals.

Search limit: To human studies and English literature.

Neonatal and paediatric studies

See table 1.

Adult studies

See supplemental table 1 available at http://adc.bmj.com/supplemental.

Commentary

Gelofuscine is a synthetic colloid, which, in recent years, has been increasingly used for volume replacement. The advantages of Gelofuscine are that it is less expensive than other synthetic colloids, is readily available and can be stored for long periods without degradation.3 4 The increased usage is also, perhaps, secondary to perceived increased risk associated with albumin infusions and other blood products.5^–7

The effects of Gelofuscine or alternative volume expansion in preterm infants have been subjected to a systematic review which included seven randomised controlled trial (RCTs).1 Out of these only one RCT investigated the use of Gelofusine for volume expansion in neonates. The Northern Neonatal Nursing Initiative (NNNI) Trial Group in this multicentre study compared the effects of prophylactic administration of fresh frozen plasma (FFP), gelatine and glucose on early mortality and morbidity in preterm infants. We did not find any evidence in the literature regarding objective evaluation of the efficacy of Gelofuscine for volume resuscitation/replacement in neonates. With regard to safety, the NNNI trial did not demonstrate any adverse short term outcomes related to Gelofuscine use.8 Developmental outcome at 2 years was also similar in the three groups.9 However, the Cochrane review by Osborn et al noted that Gelofuscine use or no treatment was associated with increased risk of developing NEC (relative risk (RR) 4.92) when compared to FFP.1 Although no significant differences in mortality or disability were found in this study and a wide confidence interval suggests an underpowered study, this finding warrants further research.

In view of the lack of appropriate studies in neonates and to further elucidate our clinical question, we extended our search to studies in the paediatric and adult population. One RCT has compared volume expansion with Gelofusine and albumin in children with severe malaria.2 Akech et al noted no significant difference in the resolution of shock or acidosis between the two groups, but fatal neurological events were more common in the group receiving Gelofusine. Five RCTs have reported on the use of Gelofusine in adults10 14 (see supplemental table 1 available at http://adc.bmj.com/supplemental). Allison et al compared the use of gelatine and HES for resuscitation in patients with blunt trauma and suggested that Gelofuscine was associated with a worse post-trauma capillary leak.10 This may be important in newborns with capillary leak syndrome such as sepsis and NEC, but relevance at present is conjectural. Schortgen et al investigated the effects of gelatine and HES on renal function in adults with severe sepsis and suggested that gelatine is safer in terms of renal function.12 No impairment of haemostasis was noted by Haisch et al following Gelofuscine use in adults undergoing major abdominal surgery.13 Rittoo et al in an RCT in adults undergoing abdominal aortic aneurysm surgery noted inferior gas exchange and lung compliance and poorer small lung injury score in the Gelofusine group compared to HES.11 Whether this has any implications in neonates with unstable lung function and in worsening lung damage needs to be elucidated.

Adult studies suggest that Gelofuscine has less antigenic properties and thus a lower chance of hypersensitivity reactions. The other potential disadvantages include the possibility of altered haemostasis15 16 and proteinuria.17 18 The relevance of these findings to the neonatal population has not been explored.

Although Gelofuscine is readily available and cheap, and less monitoring is required during infusions, there is no evidence to support its efficacy for use in volume expansion in neonates. Moreover, considering the potential side effects in preterm neonates, it should be used with caution until further studies are available to prove its safety and efficacy. This is especially pertinent considering the lack of evidence of any potential superiority of various colloids over normal saline for volume replacement.19