Albumin

OVERVIEW

  • colloid solution
  • 4, 10, 20%
  • use in the critically unwell is controversial

USES

  • -> volume replacement (SAFE showed that it is equivalent to N/S)
  • -> hypoalbuminaemia (cirrhosis, SBP -> reduces mortality and renal failure)

PREPARATION

  • prepared from pooled human plasma (donated by Australia’s voluntary non-remunerated donors)
  • heated at 60° C for 10 hours and incubated at low pH to inactivate viruses
  • clear, slightly viscous liquid; it is almost colourless, yellow, amber or green (albumin binds biliverdin, which is harmless)

4% w/v

20 % w/v = Human Albumin 200 g/L, Sodium 48 – 100 mmol/L, Octanoate 32 mmol/L

  • hyperoncotic, hypo-osmotic( osmolality of 130 mOsm/kg), isotonic and the pH is 7.

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

AN 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

References and Links

Journal articles and textbooks

  • Delaney AP, Dan A, McCaffrey J, Finfer S. The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Crit Care Med. 2011 Feb;39(2):386-91. PMID: 21248514.
  • Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27;350(22):2247-56. PMID: 15163774
  • Martin GS, Moss M, Wheeler AP, Mealer M, Morris JA, Bernard GR. A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury. Crit Care Med. 2005 Aug;33(8):1681-7. PMID: 16096441.
  • Martin G. Conflicting clinical trial data: a lesson from albumin. Crit Care. 2005;9(6):649-50. PMC1414029.
  • 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 PMID: 19281447 [Fulltext]
  • Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2012 Jun 13;6:CD000567. PMID: 22696320.
  • Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L, Vargas V, Soriano G, Guevara M, Ginès P, Rodés J. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5;341(6):403-9. PMID: 10432325.
  • Vincent JL, Dubois MJ, Navickis RJ, Wilkes MM. Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials. Ann Surg. 2003 Mar;237(3):319-34. PMC1514323.

Social media and web resources

  • Australian Blood Service — Albumin

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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