Use of albumin solution should be considered for volume replacement during or after cardiac surgery , at least in those patients at risk of bleeding or renal dysfunction bleeding . Onorati et al retrospectively compared low dose albumin to pure crystalloid priming in 377 patients . 15 Patients receiving albumin needed smaller amounts of blood transfusions and had lower blood loss postoperatively . Additionally , the rate of resternotomies was significantly less in the albumin group .
Postoperative effects In the postoperative setting , albumin has been compared with different solutions in numerous small prospective studies . In 2006 , Niemi et al demonstrated that the use of both starch and gelatin solutions correlates with the amount of postoperative bleeding after cardiac surgery , but the use of 4 % albumin solution does not . 16 Schramko et al compared the postoperative infusion in the dose of 15ml / kg of two starch solutions ( HES200 / 0.5 and HES130 / 0.4 ) to 4 % albumin : albumin did not cause any changes in maximum clot firmness , but both starch solutions decreased this parameter of thromboelastometry slightly , but significantly . 17 After administration of all colloids , cardiac index increased significantly compared to preoperative level ; however , HES solutions increased cardiac index more than albumin . Skhirtladze demonstrated that perioperative fluid balance in cardiac surgical patients was similar in albumin and HES groups , but significantly lower compared with Ringer ’ s solution . 18
Navickis et al have published meta-analysis compared use of HES solutions to albumin : haemodynamics was similar in both groups , but the use of albumin decreased blood loss , the amount of blood product transfusions required and the need for reoperation postoperatively . 19 However , this meta-analysis has insufficient data about the use of tetrastarch HES130 / 0.4 . Some investigators reported a very interesting fact : when the use of albumin solution was compared with other colloids with nonbiological origin or with crystalloids , the platelet count in the albumin group was significantly higher postoperatively then in the other fluid groups . 15 This ‘ platelet preservation ’ effect of albumin has been discussed in several forums ; however , the mechanisms of this effect are still unclear . Some studies reported slight hypocoagulation after albumin use , but these changes are caused more by a haemodilution effect . Based on these findings , the use of albumin solution after cardiac surgery is also in those patients who already have increased blood loss . The meta-analysis of controlled studies published in 2004 included 1346 patients and compared the use of albumin with crystalloid solution for CPB priming . Albumin priming preserved platelet counts better than crystalloid , and favourably influenced colloid oncotic pressure and positive fluid balance after cardiac surgery . 20
Because of its biological origin , albumin has multiple functions . It is possible that albumin coats the insides of the tubes and the reservoir of the CPB circuit and therefore reduces contact activation of leucocytes and platelets , which occurs during CPB . Albumin also has a protective effect on the endothelial glycocalix , which is damaged during CPB . 8 , 21
Conclusions At this time , debates about volume replacement therapy still continue . Some countries stopped the use of synthetic colloids because of the results of several studies in critically ill patients , which demonstrated that HES solutions probably impair renal function and even outcome . 22 Despite the fact that the conclusions of these studies are questionable and their results are impossible to extrapolate to the surgical patients , nowadays more and more hospitals have abandoned the use of synthetic colloids . Another point for this is that the use of HES solutions did not improve outcome compared to crystalloids .
The use of only crystalloids , even for volume replacement , leads to the increased amount of fluids given . Because the degree of systemic inflammatory response reaction and damage of endothelial glycocalix after cardiac surgery is high , and patients often have a lot of co-morbidities , the use of pure crystalloid volume replacement is possibly not justified . Use of albumin solution should be considered for volume replacement during or after cardiac surgery , at least in those patients at risk of bleeding or renal dysfunction .
Albumin solution provides a good haemodynamic effect , which lasts several hours without any clinically significant side-effects . In those special cases when patients are already fluid overloaded ( for example , emergency surgery or cardiac transplantation patients ), the use of small amounts of hyperoncotic albumin solution should be considered .
In the field of cardiac surgery , only data from small prospective randomised studies compared albumin with crystalloids or other colloids . We await results of large RCTs of high quality .
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