polygelatin . 16 In addition , albumin treatment after massive paracentesis lowers the incidence of complications and reduces hospital costs , making it more cost-effective than polygelatin . 17
Combination of terlipressin ( 6 – 12mg / day ) and albumin ( 1g / kg / day ) following massive paracentesis effectively prevents post-paracentesis circulatory dysfunction and hepatorenal syndrome . 18
In most critically ill patients , the albumin concentration is at least 30g / l . If possible , albumin concentrations should be maintained above 35g / l , which is the minimum level for physiological status . 19 , 20 A clinical trial involving improvement in albumin levels in critically ill patients demonstrated improved organ function , which reflected in better Sequential Organ Failure Assessment scores . 21
For example , in cirrhotic patients with ascites , albumin synthesis is markedly reduced , which causes a drop in the plasma colloid osmotic pressure . This promotes the leakage of fluid from the plasma into the abdominal cavity and increases ascites .
Human albumin infusion is the second-line treatment for cirrhotic ascites , especially for refractory cirrhotic ascites . International guidelines recommend administration of 6 – 8g of human albumin , for each 1000ml of ascites removed can prevent post-paracentesis circulatory dysfunction and increase survival rates . 22
For patients with cirrhotic ascites accompanied by spontaneous bacterial peritonitis , 1.5g / kg human albumin was administered on day 1 , and subsequently 1g / kg on days 2 – 5 . 23 There was a marked decline in the incidence of renal failure , mortality during hospitalisation , and 3-month mortality in patients with cirrhosis who received human albumin compared with those who did not . The effective blood volume is increased through the infusion of human albumin , and there is reduced activation of the renin-angiotensin-aldosterone system , which can reduce water and sodium retention and thereby reduce ascites . 24
Plasma exchange Plasma exchange is commonly performed in ICU patients . It is a process used to remove patient plasma and replace it with another solution , to maintain normal volaemia and osmotic balance , and to eliminate toxic substances such as drugs , autoantibodies , alloantibodies , immune complexes , proteins , and toxins from the plasma . 25 The treatment goal for a plasma exchange session should be between 1- and 1.5-times the patient ' s plasma volume ( estimated at 40ml / kg body weight ). This requires a significant amount of plasma , which can be difficult to obtain in clinical practice . To this effect , albumin is frequently used as the replacement solution in plasma exchange . The albumin concentration used in plasmapheresis is usually 5 %. Moreover , the use of human albumin avoids the infectious and immunological risks of infusing non-virally inactivated plasma .
Artificial liver support systems , particularly albumin dialysis ( MARS system ) and plasma separation and adsorption separation ( Prometheus system ) have been evaluated as treatment methods for liver failure . These systems remove substances that bind albumin and other substances that accumulate during liver failure . Both methods have been evaluated in large RCTs of ACLF patients and have not proved to have a significant impact on survival . 26 , 27 The MARS system can prolong the survival period of patients with acute exacerbation of chronic liver failure , while its cost-effectiveness is acceptable . 27
Brain oedema In the general ICU , spontaneous intracerebral haemorrhage ( 25 %), cranio-cerebral trauma ( 16.8 %), and cerebral infarction ( 7.3 %) account for 50 % of all ICU cases , meaning that 50 % of the ICU patients have brain oedema and require active dehydration to reduce intracranial pressure . 28
Mannitol , hypertonic saline , and human albumin are routinely employed as hyperosmolar agents . However , the latest guidelines do not recommend the use of dehydrating agents due to the lack of high-quality clinical studies to verify the effects of these hypertonic fluids on brain oedema . 29 It is not recommended to use colloidal fluids , glucose-containing hypotonic fluids , and other hypotonic fluids or albumin as maintenance fluids for neurologically critical patients ( strong recommendation ); high concentration ( 20 %– 25 %) of albumin is not recommended for patients with acute ischaemic stroke ( strong recommendation ); it is recommended to use crystalloids as the first-line resuscitation fluid for neurologically critical patients in hypotension ( weak recommendation ); it is not recommended to use low concentration ( 4 %) albumin as resuscitation fluid for neurologically critical patients in hypotension ( strong recommendation ); it is not recommended to use high-concentration ( 20 %– 25 %) albumin as a resuscitation fluid for neurologically critical patients in hypotension ( weak recommendation ). 29
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