Critically evaluate the role of albumin containing solutions in the management of the critically ill patient.
The role of albumin containing solutions in the critically ill is becoming clearer with time, but is still controversial. Earlier meta-analyses of heterogeneous trials had suggested increased mortality with albumin administration. The recently published SAFE study confirmed that 4% albumin administration was “safe” when compared with normal saline in those critically ill patients who required fluid resuscitation, but did not suggest any specificindications. The specific predetermined and stratified subset of patients where there is still significant doubt is in patients with multiple trauma where there seemed to be worse outcomes in the albumin group (in a post-hoc analysis thought mainly in those patients with severe head injury). Two prospective RCTs have demonstrated specific situations where albumin may actually be of benefit: improved oxygenation in hypo-proteinemic patients with acute lung injury (Martin CCM 2002), and improved mortality in patients with spontaneous bacterial peritonitis (Sort NEJM1999).
This question closely resembles Question 25 from the first paper of 2010.
The answer to it is reporduced below, to simplify revision
Albumin as a resuscitation fluid
Albumin for resuscitation of septic shock
Albumin for spontaneous bacterial peritonitis
Albumin for volume replacement in paracentesis
Albumin as an adjunct in hepatorenal syndrome
Albumin for extracorporeal detoxification in liver failure
Albumin as an adjunct to frusemide in ARDS
Albumin to aid water elimination in oedematous ICU patients
Albumin is to be avoided in traumatic brain injury
Much has been made of the findings of the SAFE study. The most recent ALBIOS study has supported the notion that albumin and saline are quivalent as resuscitation fluids. Furthermore, the authors found that the patients enrolled in early stages of sepsis did not demonstrate an early benefit, and that patients treated with albumin for longer tended to benefit more. This suggests that the benefit of albumin is derived not from a purely oncotic effect, but rather due to its ancillary functions as a nitric oxide modulator, antioxidant and anti-immunosuppressive. This is supported by the last salvo fired by Marik, who suggested that the contribution of albumin infusion to maintaining the integrity of the vascular endothelial glycocalyx is enough to support its role as "a reasonable intervention" in sepsis.