reduces the risk of subsequent death compared with non-protein colloids . In a study in 8084 cases , albumin use was found to be associated with 25 % lower odds of mortality compared with non-protein colloid use . 18
Further evidence of the potential mortality benefit with albumin comes from a large study in which albumin was used in conjunction with crystalloids in patients undergoing on-pump cardiac surgery for value and / or bypass procedures . Of 1095 patients who received 5 % albumin and crystalloids ( saline or lactated Ringer ’ s ) compared with a similar cohort that received crystalloids alone , the use of albumin was associated with a decreased risk of hospital mortality ( odds ratio , OR = 0.5 , 95 % CI 0.3 – 0.9 , p = 0.02 ) and lower all-cause 30-day readmission rates ( OR = 0.7 ; 98.3 % CI , 0.5 – 0.9 ; p < 0.01 ) compared with those receiving crystalloids alone . 19
Ultimately , whether albumin performs better than crystalloids both as a priming and replacement fluid is the subject of an ongoing randomized trial for which the protocol has been recently published . The trial , ALBumin In Cardiac Surgery ( ALBICS ), will examine the effect of 4 % albumin against Ringer ’ s acetate solution in CPB priming and volume replacement during surgery and the first 24 hours of intensive care stay . The primary outcome for the trial is the number of patients with at least one major adverse event during 90 postoperative days . 20 Although the results of the ALBICS trial are awaited , a review comparing the ability of crystalloids and colloids to stabilize hemodynamic endpoints within an intensive care setting concluded that colloids were more effective . 21
What do cardiovascular clinicians use for resuscitation fluids ? Given the need for fluid resuscitation during both the intra- and perioperative periods during cardiac surgery , a 2017 study sought to explore the use of fluids among 124 cardiothoracic surgeons , cardiovascular anesthesiologists and perfusionists on the most commonly used fluids . 22 The most common indices of volume status were blood pressure , urine output , cardiac output , central venous pressure and heart rate . In patients not experiencing significant blood loss , the most commonly used intravenous fluid varied depending on the role of the respondent . For example , crystalloids were cited by 58 % of anesthesiologists compared with 38 % of surgeons . The most frequent second choice of anesthesiologists was 5 % albumin ( 33 %), which was similar to surgeons ( 28 %). In contrast , where patients experienced blood loss , 52 % of anesthesiologists chose 5 % albumin compared with 38 % of surgeons . The most frequent choice of adjunctive therapy when crystalloids were used was 5 % albumin . The authors concluded that fluid utilization practices varied across the USA and were dependent to some extent on the specialties of the healthcare professional involved .
Evaluation of fluid treatment after cardiac surgery After cardiac surgery , it is necessary to determine volume status . Oxygen delivery is the focus which demands an essential amount of fluids . Post-surgery , too much fluid is harmful and an excessive fluid load can worsen a patient ’ s prognosis ( for example , through development of heart failure ). Caution should be exercised once the volume exceeds 2 – 3l , especially after the patient has completely warmed . Pulmonary edema , blood dilution , and increased perioperative blood transfusion , ALI / ARDS , impaired intestinal absorption , renal excretion , increased abdominal pressure , and volume determination require comprehensive judgment and assessment . Volume monitoring indicators are helpful ; in particular , the role of ultrasound in volume assessment . The evaluation of fluid therapy after cardiac surgery also has special considerations . For example , patients with severe myocardial hypertrophy need higher filling pressure . Long aorta clamping time reduces ventricular compliance and requires higher pressure . Ongoing fluid flow requires rapid and timely assessment for other factors that cause hemodynamic instability such as : bleeding , tamponade , tonic pneumothorax , valvular dysfunction , myocardial ischemia and heart failure . Echocardiography is clinically useful , especially in situations of unclear hemodynamics . A small transesophageal echocardiography probe may stay in place for 72 hours and is useful for guiding resuscitation . Pulse contour cardiac output monitoring is restricted due to thoracotomy and limited accuracy .
Conclusion Albumin is used in the perioperative management of cardiac surgery and its use is associated with improvements in plasma osmotic pressure and the expansion effects . It can better maintain tissue perfusion , has anti-inflammatory effects , improves vascular endothelial integrity , and affects coagulation function . Albumin does not cause clinical edema , thereby helping to achieve the goal of improving the success rate of surgery and conferring long-term survival benefits .
References 1 Schumacher J , Klotz K-F . Fluid therapy in cardiac surgery patients . Appl Cardiopulmonary Pathophys 2009 ; 13:138 – 42 . 2 Linden MD . The hemostatic defect of cardiopulmonary bypass . J Thromb Thrombolysis 2003 ; 16 ( 3 ): 129 – 47 . 3 Lannemyr L et al . Effects of cardiopulmonary bypass on renal perfusion , filtration , and oxygenation in patients undergoing cardiac surgery . Anesthesiology 2017 ; 126:205 – 13 . 4 Nutall GA et al . Efficacy of a simple intraoperative transfusion algorithm for non-erythrocyte component utilization after cardiopulmonary bypass . Anesthesiology 2001 ; 94 ( 5 ): 773 – 81 . 5 Despotis GJ et al . Mechanisms and attenuation of hemostatic activation during extracorporeal circulation . Ann Thorac Surg 2001 ; 72 : S1821 – 31 . |
6 Hamada Y et al . Capillary leakage in cardiac surgery with cardiopulmonary bypass . Asian Cardiovasc Thorac Ann 2004 ; 12 ( 3 ): 193 – 7 . 7 Onorati F , Santarpino G , Renzulli A . Does priming implementation with lowdose albumin reduce postoperative bleeding following cardiopulmonary bypass ? Int J Artif Organs 2003 ; 26 ( 3 ): 211 – 6 . 8 Moret E et al . Albumin – Beyond fluid replacement in cardiopulmonary bypass surgery : Why , how , and when ? Semin Cardiothorac Vasc Anesth 2014 ; 18 ( 3 ): 252 – 9 . 9 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 ( 4 ): 429 – 37 . 10 Lewis SR et al . Colloids versus crystalloids for fluid resuscitation in critically ill |
people . Cochrane Database Sys Rev 2018 ;( 8 ): CD000567 . 11 Brandstrup B et al . Effects of intravenous fluid restriction on postoperative complications : comparison of two perioperative fluid regimens : a randomized assessor-blinded multicenter trial . Ann Surg 2003 ; 238 ( 5 ): 641 – 8 . 12 Jacob M et al . Small-volume resuscitation with hyper-oncotic albumin : a systematic review of randomized clinical trials . Crit Care 2008 ; 12 : R34 . 13 Mårtensson J et al . Small volume resuscitation with 20 % albumin in intensive care : physiological effects : The SWIPE randomized clinical trial . Intensive Care Med 2018 ; 44:1797 – 806 . 14 Groeneveld ABJ , Navickis RJ , Wilkes MM . Update on the comparative safety of colloids : a systematic review of clinical studies . Ann Surg |
2011 ; 253 ( 3 ): 470 – 83 . 15 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 ( 1 ): 223 – 30 . 16 Wilkes MM , Navickis RJ , Sibbald WJ . Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery : a meta-analysis of postoperative bleeding . Ann Thorac Surg 2001 ; 72 ( 2 ): 527 – 33 . 17 Bayer O et al . Perioperative fluid therapy with tetrastarch and gelatin in cardiac surgery – a prospective sequential analysis . Crit Care Med 2013 ; 41 ( 11 ): 2532 – 42 . 18 Sedrakyan A et al . Volume expansion with albumin decreases mortality after coronary artery bypass graft surgery . Chest 2003 ; 123 ( 6 ): 1853 – 7 . |
19 Kingeter AJ et al . Association between albumin administration and survival in cardiac surgery : a retrospective cohort study . Can J Anesth 2018 ; 65:1218 – 27 . 20 Vlasov H et al . Effect and safety of 4 % albumin in the treatment of cardiac surgery patients : study protocol for the randomized , double-blind , clinical ALBICS ( Albumin In Cardiac surgery ) trial . Trials 2020 ; 21:235 . 21 Martin GS , Bassett P . Crystalloids vs . colloids for fluid resuscitation in the intensive care unit : a systematic review and meta-analysis . J Crit Care 2019 ; 50:144 – 54 . 22 Aronson S , Nisbet P , Bunke M . Fluid resuscitation practices in cardiac surgery patients in the USA : a survey of health care providers . Perioper Med ( Lond ) 2017 ; 19 ; 6:15 . |
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