COCHRANE, ALBUMIN AND HYPOVOLEMIA

I can´t remember ever having used albumin solutions for any patient and definitely not in hypovolemia. The SAFE study erased the remaining doubts I had. 

Furthermore there is a recently published Cochrane study that finds no evidence for reduced mortality after using albumin solutions for hypovolemia, burns or even hypoalbuminemia.

The Cochrane study can be found here.  Abstract below.

Regarding the header image. For some reason it was one of the first five hits when image googling albumin. Hmmm.

The only problem I have with the Cochrane stuy is that with the study selection criteria the SAFE study patients comprise 75% of the Cochrane study material. What is up with that?

The Albumin Reviewers. 
Human albumin solution for resuscitation and volume expansion in critically ill patients. 
Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. (Review

BACKGROUND: Human albumin solutions are used for a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, such as in burns and hypoproteinaemia. Human albumin solutions are more expensive than other colloids and crystalloids.


OBJECTIVES: To quantify the effect on mortality of human albumin and plasma protein fraction (PPF) administration in the management of critically ill patients.

SELECTION CRITERIA: Randomised controlled trials comparing albumin or PPF with no albumin or PPF or with a crystalloid solution in critically ill patients with hypovolaemia, burns or hypoalbuminaemia.

DATA COLLECTION AND ANALYSIS: We collected data on the participants, albumin solution used, mortality at the end of follow up, and quality of allocation concealment. Analysis was stratified according to patient type.


MAIN RESULTS: We found 38 trials meeting the inclusion criteria and reporting death as an outcome. There were 1,958 deaths among 10,842 trial participants.For hypovolaemia, the relative risk of death following albumin administration was 1.02 (95% confidence interval (CI) 0.92 to 1.13). This estimate was heavily influenced by the results of the SAFE trial, which contributed 75.2% of the information (based on the weights in the meta-analysis). For burns, the relative risk was 2.93 (95% CI 1.28 to 6.72) and for hypoalbuminaemia the relative risk was 1.26 (95% CI 0.84 to 1.88). There was no substantial heterogeneity between the trials in the various categories (Chi(2) = 26.66, df = 31, P = 0.69). The pooled relative risk of death with albumin administration was 1.05 (95% CI 0.95 to 1.16).


AUTHORS’ CONCLUSIONS: For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trials.

So there you have it. And here’s a link to the SAFE study, NEJM 2004. Well worth a read.

Update feb 2012: Underway is a new albumin RCT: PRECISE. They think they have identified a subgroup of severe sepsis patients, where albumin might reduce mortality. They will be testing 5% albumin against normal saline on 90-day mortality as an early septic shock resuscitation trial. It seems like clinging to the last straw, but let’s see what PRECISE can bring us.

This entry was posted in Emergency Medicine, Intensive Care, Trauma and tagged , , . Bookmark the permalink.

One Response to COCHRANE, ALBUMIN AND HYPOVOLEMIA

  1. Pingback: COLLOIDS VS CRYSTALLOIDS | ScanCrit.com

Leave a Reply

Your email address will not be published. Required fields are marked *