the late 1990s , albumin solutions had been used in various clinical indications on the basis of different levels of evidence ( Table 2 ). Subsequently , large-scale clinical trials have been performed . Their results are now available , confirming the safety of human albumin , and which also provide high-grade levels of evidence for its modern therapeutic use .
Liver disease In cirrhotic patients with ascites , the therapeutic goal of treatment with albumin is not only limited to the maintenance of COP but also to improving effective circulating blood volume because splanchnic vasodilation reduces blood volume at the central level with activation of the renin – angiotensin system , sodium retention and development of ascites . 12 The appearance of refractory ascites , that is , resistant to the administration of diuretics , represents an established indication for the use of albumin , when large volume paracentesis is performed leading to improved morbidity and mortality . 12 In cirrhotic patients , additional indications include spontaneous bacterial peritonitis ( 1.5g / kg on day 1 and 1g / kg on day 3 ) and hepato-renal syndrome in association with vasoconstrictors ( 1g / kg on day 1 then 20 – 40g / day for 2 weeks ). 13
Sepsis Severe sepsis and septic shock are characterised by micro-vascular leakage into the interstitium due to increased capillary permeability , production of proinflammatory cytokines and severe hypovolaemia . This results in a reduction in blood pressure and insufficient blood supply to major organs , with the risk of developing multiple organ failure . Volume resuscitation by intravenous administration of crystalloids and albumin , combined with vasoactive amines and early surgical and / or antibiotic therapy of infection , are crucial in the treatment of severe sepsis and septic shock . Artificial colloids are harmful in these situations . Updated guidelines 14 suggest the use of albumin in the presence of at least one the following conditions :
• evidence of increased capillary permeability ( pulmonary oedema and / or oedema peripheral );
• failure to respond to the initial administration of at least 2l of crystalloid given in the first three
hours .
Surgery In surgical patients , according to guidelines used by some hospitals , the use of albumin may be indicated in patients undergoing major surgery ( liver resection > 40 %, large bowel resection ) if , after normalisation of blood volume , serum albumin is < 2g / dl . 9 , 15 The use of albumin in cardiac surgery is recommended in various guidelines for both filling of the heart – lung machine and to reduce oedema perioperatively . 16 , 17 The synthetic colloids have been shown to increase postoperative bleeding and number of reoperations in several clinical studies and meta-analysis . 18
Burns In burns , albumin is not the therapy of first choice in the first 24 hours , when crystalloids are to be used . In accordance with guidelines , albumin solutions are associated with crystalloids when burns cover more than 30 % body surface area and with albumin levels less than 20g / l or when crystalloid therapy was not effective in the correction of hypovolemia . 19
Plasmapheresis For plasmapheresis , human albumin is primarily recommended compared with crystalloids or synthetic colloids , when the plasma exchange procedure concerns large plasma volumes (> 20ml / kg in one sitting , or > 20ml / kg per week in case of repeated procedures ). Crystalloid and albumin / crystalloid combinations are cost-effectiveness alternatives for plasmapheresis at smaller volumes . 10
Ovarian hyperstimulation syndrome In ovarian hyperstimulation syndrome , use of albumin solutions in nine randomised controlled trials decreased the odds of ovarian hyperstimulation syndrome compared with placebo . 21 In the literature , results are mixed and additional evidence is needed to conclusively state that albumin administration is beneficial .
Conclusions Appropriate use of albumin solutions in hospitals is subject to guideline recommendations and control . Considering the latest publications on the tolerability of the synthetic colloids and their risk of adverse reactions , recommendations for colloids ‘ use will increasingly differentiate between natural and artificial , in particular when volume resuscitation in intensive care and surgery is concerned . Current guidelines strongly recommend the inclusion of albumin solutions in the circulatory support in certain critically ill patients and in complications of cirrhosis of the liver .
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Practice Guidelines for the management of patients with decompensated cirrhosis . J Hepatol 2018 ; 69:406 – 60 . 14 Rhodes A et al . Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock : 2016 . Intensive Care Med 2017 ; 43 : 304 – 77 . 15 Haynes GR , Navickis RJ , Wilkes MM . Albumin administration : what is the evidence of clinical benefit ? A systematic review of randomized controlled trials . Eur J Anaestheslol 2003 ; 20:771 – 3 . 16 Russell JA , Navickis RJ , Wilkes MM . Albumin versus crystalloid for pump priming in cardiac surgery : meta-analysis of controlled trials . J Cardiothorac Vasc Anesth 2004 ; 18:429 – 37 . 17 Kingeter AJ et al . Association between albumin administration |
and survival in cardiac surgery : a retrospective cohort study . Can J Anaesth 2018 ; 65:1218 – 27 . 18 Navickis RJ , Haynes GR , Wilkes MM . Effect of hydroxyethyl starch on bleeding after cardiopulmonary bypass : a meta-analysis of randomized trials . J Thorac Cardiovasc Surg 2012 ; 144:223 – 30 . 19 Cochran A et al . Burn patient characteristics and outcomes following resuscitation with albumin . Burns 2007 ; 33:25 – 30 . 20 Cartotto R , Greenhalgh D . Colloids in acute burn resuscitation . Crit Care Clin 2016 ; 32:507 – 23 . 21 Youssef MA et al . Intra-venous fluids for the prevention of severe ovarian hypersimulatian syndrome . Cochrane Database Syst Rev 2011 ; 16 : CD001302 . |
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