HPE Human albumin handbook | Page 19

Albumin administration in the ICU : For whom and when ?

Human albumin is one of the most frequently used drugs in the ICU . This article explores its indications for use and effectiveness in critical care
Dechang Chen MD Department of Critical Care Medicine , Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , China
Jiao Liu MD Yanxia Huang Department of Critical Care Medicine , Ruijin Hospital North , Shanghai Jiao Tong University School of Medicine , China
Yuetian Yu MD Department of Critical Care Medicine , Renji Hospital , Shanghai Jiao Tong University School of Medicine , China
Human albumin , as a therapeutic drug , is used in an increasing number of situations in the ICU . In early days , it was primarily used to supplement albumin levels in chronic liver disease . Nowadays , it is more often used to maintain circulatory stability of critical patients , 1 , 2 and also has an important role in the treatment of severely ill patients . The potential clinical benefits of human albumin in patients with sepsis appear to be associated with immunomodulatory and antiinflammatory effects , antibiotic transport , and endothelial stability . Albumin exerts an immunomodulatory effect by binding to several bacterial products and acts as a carrier for many drugs that are used in the treatment of critically ill patients . 1
Although albumin has a wide application , controversies still remain . How do we use albumin best ? Which patients benefit the most from albumin treatment ? When should albumin be used ?
A survey on human albumin administration in critical illness showed that only 5.3 % of responders preferred to use albumin in the critically ill patient . 3 Here we will discuss the use of human albumin in these patients .
Sepsis and septic shock Septic shock is a medical emergency . Treatment including fluid resuscitation should be initiated immediately . The mortality of septic shock patients is around 50 %. 4 Fluid resuscitation is the key therapy for sepsis and septic shock .
Human albumin is a commonly used resuscitation fluid in clinical practice . Its role in fluid resuscitation for patients with sepsis is still inconclusive . To date , several randomised controlled trials ( RCTs ) have evaluated the role of human albumin solution for resuscitation in septic patients .
The SAFE study published in 2004 showed that albumin administration was safe and as effective as 0.9 % saline for fluid resuscitation . 5 A meta-analysis demonstrated that human albumin solution was not effective for resuscitation in sepsis patients with or without baseline hypoalbuminaemia . 6 However , several falsified trials were included in the metaanalysis , which would cause bias . Two other metaanalyses 7 , 8 found a reduction in mortality ; therefore , the debate continues . The ALBIOS trial showed no mortality benefit of albumin in combination with crystalloids compared with crystalloids alone in patients with sepsis ( relative risk ( RR ) 0.94 ; 95 % CI 0.85 – 1.05 ). 9 However , a subgroup analysis suggested that the albumin group was associated with lower 90-day mortality in patients with septic shock ( RR 0.87 ; 95 % CI 0.77 – 0.99 ). 9 Xu et al evaluated the use of albumin compared with crystalloid as a resuscitation fluid . 10 Human albumin administration resulted in reduced 90-day mortality in septic shock ( odds ratio ( OR ) 0.81 ; 95 % CI 0.67 – 0.97 ) and trended toward reduced 90-day mortality in sepsis ( OR 0.88 ; 95 % CI 0.76 – 1.01 ; p = 0.08 ). Debate persists , but the overall trend is that albumin might reduce mortality .
In the Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock , 4 crystalloids are the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock . However , the guidelines also suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids . In this guideline , human albumin is not the recommended first-line fluid ; it is recommended only when the patient requires significant fluid resuscitation . New evidence suggests that albumin might be beneficial in septic shock , but other colloids such as starch , dextran , and gelatin appear to increase the risk of death and acute kidney injury .
The timing of giving human albumin solution during fluid resuscitation in patients with sepsis has not been studied in RCTs . In the EARSS study , human albumin was given within three days after randomisation . 11 The RASP study is the only study describing infusion of human albumin solution six hours after randomisation . However , this study shows that in cancer patients with septic shock , administering human albumin solution within six hours of initial shock resuscitation , compared with crystalloid resuscitation , did not improve patient outcomes . 12 It is worth noting that the RASP study included patients with septic shock whose underlying disease was cancer . Therefore , the results of this study have limitations . So far there is no direct evidence to inform the timing of giving human albumin solution during resuscitation for septic patients during clinical decision-making .
Hypoalbuminaemia due to chronic liver disease Hypoalbuminaemia is frequently observed and shown to be significantly associated with poor clinical outcomes in critically ill patients , especially those patients with chronic liver disease . 13 , 14 In ANSWER study , long-term injection of albumin ( 40g twice a week for 2 weeks , then 40g a week for up to 18 months ) extended the overall survival and was established as an optimal therapy for patients with decompensated liver cirrhosis . 15 The therapeutic efficacy and safety of albumin are superior to other volume expanders , such as dextran and
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