Compare and contrast albumin and gelatins (Haemaccel and Gelofusin) as volume replacement fluids in the critically ill patient.

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College Answer

Albumin

Haemaccel &
Gelofusin

Pharmacology

5% and 20%,
naturally occuring

Semisynthetic,
Produced from bovine collagen

Shelf life

1 yr shelf life at
room temperature

Long shelf lives

Indications for use

Used for treatment
of hypovolemia and hypoalbuminemia

Used for
hypovolemia

Published data

Proven to be
similar to crystalloids in SAFE study

Tendency for better
outcome in sepsis but worse outcome in head injured patients

No published data
in critical illness, regarded as safe, Haemaccel can’t be used with citrated blood

Side effects

No risk of
anaphylaxis, no effect on clotting

Lower risk of
anaphylaxis than haemaccel, no proven effect on clotting other than thro dilution

Complications

Risk of CJ disease

No risk or lesser
risk of CJ disease

Discussion

Physiological responses to concentrated human albumin and to Gelofusine are discussed in greater detail elsewhere. Haemaccel is not used locally, and thus I have never had very much interest in it (sorry, Haemaccel enthusiasts).

This question asks the candidate to compare and contrast them as volume replacement fluids in the critically ill patients. Sukanaya Mitra published a 2009 paper which goes some of the way towards answering this question for us; it summarises the key concepts, and expands on the range of colloids by also discussing the hydroxyethyl starches and dextrans.

Out of respect for this paper, I will make an attempt to summarise it into a table format.

A Comparison of Colloidal Volume Replacement Solutions
Property Albumin (20%) Gelofusine 4% Dextran (10%) Hydroxyethyl starch 6%
Drug class Endogenous protein Succynylated bovine gelatin Branched polysaccharide Amylopectin derivative
Molecular weight 69 000 Da 5 000 - 15 000 Da 14 000-18 000 Da 70 000 Da
Plasma halflife 24 hours 2.5 hours 12 hours 5 days
Elimination Degradation by reticuloendothelial system Renally excreted Renally excreted Some renally excreted,
some metabolised by the reticuloendothelial system
Plasma expansion as a percentage of infused volume 200-400% 70-80% 100-150% ~100%
Advantages

Antioxidant effects

Free radical scavenging effects

Protection of glycocalyx

Cheap

Relatively safe in renal failure

No limits on infused volume

Decreases the viscosity of blood, improving microcirculation

No risk of CJ disease

Cheap

Large maximum allowable volume

No risk of CJ disease

Lowest risk of anaphylactoid recations among non-albumin colloids

Disadvantages

Volume overload

Transfusion reaction

Expensive

Risk of CJ disease

Volume overload

Anaphylactoid reactions

Coagulopathy

Volume overload

Anaphylaxis

Coagulopathy

Interference with ABO crossmatch

Renal failure (ATN)

Volume overload

Anaphylactoid reactions

Coagulopathy

Accumulation

Renal failure

Increase in amylase


Evidence:

  • Albumin was found to be equivalent (in terms of mortality) to crystalloid (SAFE study)
  • Dextrans are the least favoured in critical illness (renal impariment, coagulopathy etc)
  • Gelatins are widely disliked due to the increased potential for anaphylactoid reactions
  • Hydroxyethyl starch has the least adverse effects, but its use has been discouraged by the findings of the CHEST study(increased rates of renal failure)

References

The albumin page and Gelofusine page are extensively referenced and I will not reproduce that stuff here.

 

Mitra, Sukanya, and Purva Khandelwal. "Are all colloids same? How to select the right colloid?." Indian journal of anaesthesia 53.5 (2009): 592.

 

Finfer, Simon, et al. "A comparison of albumin and saline for fluid resuscitation in the intensive care unit." N Engl j Med 350.22 (2004): 2247-2256.

 

Ertmer, Christian, et al. "Relevance of non-albumin colloids in intensive care medicine." Best Practice & Research Clinical Anaesthesiology 23.2 (2009): 193-212.

 

Myburgh, John A., et al. "Hydroxyethyl starch or saline for fluid resuscitation in intensive care." New England Journal of Medicine 367.20 (2012): 1901-1911.