Use in the Critically Unwell = Controversial

Albumin

22/10/10

SP Notes

- colloid solution

- 4, 10, 20%

- use in the critically unwell = controversial

- uses:

-> volume replacement (SAFE showed that it is equivalent to N/S)

-> hypoalbuminaemia (cirrhosis, SBP -> reduces mortality and renal failure)

PREPARATION

- pooled solution

- by-product of whole blood fractionation

ARGUMENTS AGAINST

- possible infection transmission

- possible allergic reactions

- very expensive (most expensive colloid) -> unable to be used in developing countries

ARGUMENTS FOR

- rates of infection transmission extremely low

- free in Australia

EVIDENCE

Cochrane meta-analysis (1998)

- 24 trials

- 1419 patients

- albumin vs N/S in hypovolaemia, burns and hypovolaemia

-> increased mortality (6% increase in absolute risk of death)

Meta-analysis (2001)

- 55 trials

- 3504 patients

-> no significant increase in mortality

Martin (CCM, 2002)

- RCT demonstrating improved mortality with albumin through improved oxygenation to hypo-proteinaemic patients with ALI.

Sort (NEJM, 2002)

- RCT showing improved mortality in patients with spontaneous bacterial peritonitis.

SAFE trial (NEJM, 2004)

- MRCT

- n = 6997

- primary end points: 28 day mortality

- powered to detect a 3% absolute reduction in mortality

- confirmed that 4% albumin was ‘safe’ when compared to normal saline in the critically unwell requiring fluid resuscitation.

- post hoc analysis showed that patients with TBI and major trauma had worse outcomes with albumin and patients with septic shock tended to better with albumin.

- ARDS patients do better with albumin.

Martin (CCM, 2005)

- patients who are hypoproteinaemic with ARDS when given albumin + frusemide vs frusemide alone

-> improved oxygenation

-> improved haemodynamic stability

Myburgh, J. A. and Finfer, S. (2009) “Albumin is a Blood Product too – is it safe for all patients?” Critical Care and Resuscitation, 11:67-70

- SAFE as compared to N/S (except in TBI)

- possible trend to decreased mortality in severe sepsis (needs further investigation)

- hypoalbuminaemia is associated with increased mortality -> volume resuscitation with albumin doesn’t reduce

-> mortality

-> duration of ICU stay

-> duration of mechanical ventilation

-> duration of RRT

- no substantive evidence to justify use of hyperoncotic albumin although we it does increase intravascular volume from its oncotic effect

- expensive

MY APPROACH

- use in spontaneous bacterial peritonitis

- can use in resuscitation of ICU patients (except those with TBI)

- use in ARDS in patients with low albumin with frusemide

- may be associated with benefit in severe sepsis (awaiting further studies)

- I don’t use to correct hypoalbuminaemia

- don’t use hyperoncotic albumin

- recognize expense and increase transfusion related risks

Jeremy Fernando (2011)