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1.
Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality?
Cooper DJ, Myburgh J, Heritier S, Finfer S, Bellomo R, Billot L, Murray L, Vallance S, SAFE-TBI Investigators, Australian, et al
Journal of Neurotrauma. 2013;30((7):):512-8.
Abstract
Mortality is higher in patients with traumatic brain injury (TBI) resuscitated with albumin compared with saline, but the mechanism for increased mortality is unknown. In patients from the Saline vs. Albumin Fluid Evaluation (SAFE) study with TBI who underwent intracranial pressure (ICP) monitoring, interventional data were collected from randomization to day 14 to determine changes in ICP (primary outcome) and in therapies used to treat increased ICP. Pattern mixture modelling, designed to address informative dropouts, was used to compare temporal changes between the albumin and saline groups, and 321 patients were identified, of whom 164 (51.1%) received albumin and 157 (48.9%) received saline. There was a significant linear increase in mean ICP and significantly more deaths in the albumin group compared with saline when ICP monitoring was discontinued during the first week (1.30+0.33 vs. -0.37+0.36, p=0.0006; and 34.4% vs. 17.4%; p=0.006 respectively), but not when monitoring ceased during the second week (-0.08+0.44 vs. -0.23+0.38, p=0.79; and 18.6% vs. 12.1%; p=0.36 respectively). There were statistically significant differences in the mean total daily doses of morphine (-0.42+0.07 vs. -0.66+0.0, p=0.0009), propofol (-0.45+0.11 vs. -0.76+0.11; p=0.034) and norepinephrine (-0.50+0.07 vs. -0.74+0.07) and in temperature (0.03+0.03 vs. 0.16+0.03; p=0.0014) between the albumin and saline groups when ICP monitoring ceased during the first week. The use of albumin for resuscitation in patients with severe TBI is associated with increased ICP during the first week. This is the most likely mechanism of increased mortality in these patients.
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2.
Influence of different volume therapies on platelet function in the critically ill
Boldt J, Muller M, Heesen M, Heyn O, Hempelmann G
Intensive Care Medicine. 1996;22((10):):1075-81.
Abstract
OBJECTIVE Both albumin and synthetic colloids such as hydroxyethyl starch (HES) solution are used to optimize hemodynamics in the critically ill. The influence of different long-term infusion regimes on platelet function was studied. DESIGN Prospective, randomized study. SETTING Clinical investigation on a university hospital surgical intensive care unit. PATIENTS Twenty-eight consecutive trauma patients (injury severity score > 15 points) and 28 consecutive nontraumatized surgical patients with sepsis. INTERVENTIONS The patients received either 20% human albumin (HA trauma, n = 14; HA sepsis, n = 14) or 10% low-molecular-weight HES solution HES 200/0.5 (HES trauma, n = 14; HES sepsis; n = 14) for 5 days to maintain central venous pressure and/or pulmonary capillary wedge pressure between 12 and 16 mmHg. MEASUREMENTS AND RESULTS Platelet function was assessed by aggregometry (= turbidimetric technique) using adenosine diphosphate 2.0 mumol/l, collagen 4 microliters/ml, and epinephrine 25 mumol/l as inductors. Arterial blood was sampled on the day of admission or the day of diagnosis of sepsis (= baseline value) and over the next 5 days. Standard coagulation parameters (antithrombin III, fibrinogen, partial thromboplastin time) were also measured. Total use of HES by the 5th day totalled 4870 +/- 990 ml in the trauma and 3260 +/- 790 ml in the sepsis patients (HA trauma: 1850 +/- 380 ml; HA sepsis: 1790 +/- 400 ml). Maximum platelet aggregation decreased significantly during the first 2-3 days after baseline in all groups. At the end of the investigation period, platelet aggregation variables had recovered and reached (or even exceeded) baseline values. Within the entire investigation period, the course of platelet aggregation variables did not differ significantly between HA and HES-treated patients irrespective of whether they were trauma or sepsis patients. CONCLUSIONS Alterations in hemostasis may occur for several reasons in the critically ill. Human albumin is the preferred first-line volume therapy in patients at risk for coagulation disorders. With respect to platelet function, volume replacement with (lower-priced) low-molecular-weight HES solutions can be recommended in this situation without any risk.
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3.
The use of albumin in clinical practice
Erstad BL, Gales BJ, Rappaport WD
Archives of Internal Medicine. 1991;151((5):):901-11.
Abstract
The use of albumin in the clinical setting continues to generate controversy. Periodic shortages and the high cost of albumin have compelled many hospitals to develop guidelines regarding albumin administration. Our purpose is to review the human studies involving albumin. Particular emphasis will be placed on comparative trials involving albumin and the less expensive crystalloid solutions. It is hoped that this review will assist the clinician in making judgements concerning the appropriate use of albumin. [References: 78]
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4.
The cardiac effect of altered calcium homeostasis after albumin resuscitation
Kovalik SG, Ledgerwood AM, Lucas CE, Higgins RF
Journal of Trauma-Injury Infection & Critical Care. 1981;21((4):):275-9.
Abstract
Supplemental albumin added to a standard non-albumin resuscitation regimen has been shown to significantly impair heartwork in seriously injured patients. The role of calcium dynamics in this myocardial depression was analyzed in 94 injured patients who were in shock for an average of 32 minutes, received an average of 14.5 transfusions, 9.2 L crystalloid, 0.9 L plasma, and 20.9 mEq calcium prior to the end of operation. By random selection, 44 patients received an average of 31 gms of albumin during operation, 207 gms during the early postoperative period (mean = 30 hrs) of extravascular fluid sequestration, and 402 gm during the mobilization period. The albumin resuscitated patients had normal total protein and serum albumin levels and higher total calcium (TC) levels, however, they had a significantly lower Ca++ and Ca++/TC. The accumulative slope for heartwork/filling pressure was significantly depressed in albumin patients as was the mean work unit/filling pressure index. The level of Ca++ and the Ca++/TC ratio correlated directly with the calculated work unit index in both the albumin and non-albumin patients. This suggests that a supplemental albumin binds serum Ca++ causing an increase in TC but a reduction in Ca++ and Ca++/TC. The fall in Ca++ and Ca++/TC seems responsible, in part, for heart failure and pulmonary edema in albumin resuscitated patients.
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5.
Differential serum protein changes following supplemental albumin resuscitation for hypovolemic shock
Lucas CE, Bouwman DL, Ledgerwood AM, Higgins R
Journal of Trauma-Injury Infection & Critical Care. 1980;20((1):):47-51.
Abstract
The effects of supplemental albumin infusion on serum protein homeostasis were studied in 94 seriously injured patients who received an average of 14.4 transfusion, 9.2 L electrolyte solution, and 829 ml fresh frozen plasma before and during operation. Based on randomization, 46 patients received an average of 31 gm albumin during operation followed by 150 gm/day for 5 days; 48 patients received no albumin. Supplemental albumin caused a significant (p = less than 0.05) increase in total serum protein and albumin concentrations. In contrast, supplemental albumin caused a significant decrease in alpha 1 globulin, alpha 2 globulin, beta globulin, gamma globulin, and fibrinogen levels. The prothrombin time used as index of prothrombin concentration was significantly prolonged in albumin patients. These changes, not previously documented, need further evaluation to determine clinical significance.
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6.
Altered coagulation after albumin supplements for treatment of oligemic shock
Johnson SD, Lucas CE, Gerrick SJ, Ledgerwood AM, Higgins RF
Archives of Surgery. 1979;114((4):):379-83.
Abstract
Coagulation and need for postoperative blood and plasma therapy were studied in 94 injured patients requiring massive transfusions (average = 14.4); 46 patients, by random selection, received supplemental albumin. Albumin therapy increased total protein concentration (6.4 vs 5.8 g/dL), serum albumin level (4.2 vs 2.9 g/dL), and plasma volume (3,895 vs 3,579 mL) but not RBC volume (1,520 vs 1,530 mL). During the initial five postoperative days, patients receiving albumin required more transfusions (7.1 vs 3.8) and plasma (455 vs 317 mL). This increased need for blood and plasma correlated with a significant decrease in fibrinogen (238 vs 405 mg/dL) and prolongation of the prothrombin time (2.6 vs 1.4 seconds). The partial thromboplastin time was prolonged and the platelet concentration was decreased in albumin-treated patients, but not significantly. Deficiencies in specific coagulation factors have not yet been identified but are being studied. Impaired coagulation is another potential hazard of supplemental albumin therapy, which is probably contraindicated in injured patients.
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7.
Pulmonary effects of albumin resuscitation for severe hypovolemic shock
Weaver DW, Ledgerwood AM, Lucas CE, Higgins R, Bouwman DL, Johnson SD
Archives of Surgery. 1978;113((4):):387-92.
Abstract
The effect of albumin when added to the resuscitation regimen of patients in hypovolemic shock was studied in a randomized prospective manner in 52 injured patients who received an average of 15.3 transfusions, 9.6 liters of balanced electrolyte solution, and 980 ml of fresh frozen plasma. Before and during operation, 27 patients received an average of 25 gm of albumin and 150 gm/day for three to five days. Patients who received albumin had greater dependence on respiratory support, averaging eight days while receiving ventilatory support with volume ventilator compared with three days in patients not receiving albumin. Furthermore, patients receiving albumin had forced inspiratory oxygen/Pao2 ratios that were statistically and significantly higher than those of patients not receiving albumin during all phases of their hospital course. These effects were associated with increased plasma volumes caused by the oncotic effects of albumin and by its interference with saline diuresis. On the basis of this preliminary report, albumin seems to have a detrimental effect on respiratory function.