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Human albumin: benefits

resuscitation by intravenous administration of crystalloids and albumin, combined with vasoactive amines and early surgical and/or antibiotic therapy of infection, are crucial in the treatment of severe sepsis and septic shock. Artificial colloids are harmful in these situations. Updated guidelines14 suggest the use of albumin in the presence of at least one the following conditions: ● evidence of increased capillary permeability (pulmonary oedema and/ or oedema peripheral);

● failure to respond to the initial administration of at least 2 litres of crystalloid.

In surgical patients, according to guidelines used by some hospitals, the use of albumin may be indicated in patients undergoing major surgery (resection liver> 40%, large bowel resection) if, after normalisation blood volume, serum albumin is <2 g/dL.9,15

The use of albumin

in cardiac surgery is recommended in various guidelines for both filling of the heart-lung machine and perioperatively to reduce oedema.16

have been shown in several clinical studies and meta-analysis to increase postoperative bleeding and number of reoperations.17

In burns, albumin is not the therapy of first choice in the first 24 hours, when crystalloids are to be used. In accordance with guidelines, albumin solutions are associated with crystalloids when burns cover more than 30% body surface area and with albumin levels less than 20g/l or when crystalloid therapy was not effective in the correction of hypovolemia.18 For plasmapheresis, human albumin is primarily recommended as compared to crystalloids or synthetic colloids, when the plasma exchange procedure concerns large plasma volumes (> 20 ml/kg in one sitting, or > 20ml/kg per week in case of repeated procedures). Crystalloid and albumin/crystalloid combinations are cost-effectiveness alternatives for plasmapheresis at smaller volumes.10 In ovarian hyperstimulation syndrome, use of albumin solutions has been investigated in several clinical studies that showed effectiveness of colloid administration in the prevention of this syndrome.19

Conclusions 10

Appropriate use of albumin solutions in hospitals is subject to guideline recommendations and control. Considering the latest publications on the tolerability of the synthetic colloids and

The synthetic colloids

their risk of adverse reactions, recommendations for colloids’ use will increasingly differentiate between natural and artificial, in particular when volume resuscitation in intensive care and surgery is concerned. Current guidelines strongly recommend the inclusion of albumin solutions in the circulatory support in certain critically ill patients and in complications of cirrhosis of the liver. ●

References 1. Quinlan GJ, Martin GS, Evans TW. Albumin: biochemical properties and therapeutic potential. Hepatol 2005;41:1211–9.

2. Mitzner S et al. Albumin-bound substances – a new target in liver failure therapy. Z Gastroenterol 2001;39 Suppl 2:6–7.

3. Bertucci C, Domenici E. Reversible and covalent binding of drugs to human serum albumin: methodological approaches and physiological relevance. Curr Med Chem 2002;9:1463–81.

4. Inoue M et al. Mechanism of furosemide resistance in analbuminemic rats and hypoalbuminemic patients. Kidney Int 1987;32:198–203.

5. Keaney JF Jr et al. NO forms an adduct with serum albumin that has endothelium-derived relaxing factor-like properties. J Clin Invest 1993;91:1582–9.

6. Demling RH. Effect of plasma and interstitial protein content on tissue edema formation. Curr Stud Hematol Blood Transfus 1986;53:36–52.

7. Zhang WJ, Frei B. Albumin selectively inhibits TNF alpha-induced expression of vascular cell adhesion molecule-1 in human aortic endothelial cells. Cardiovasc Res 2002;55:820–9.

8. Wiedermann CJ, Wiedermann W, Joannidis M. Hypoalbuminemia and acute kidney injury: a meta-analysis of observational clinical studies. Intens Care Med 2010;36:1657–65.

9. Vincent JL, Navickis RJ, Wilkes MM. Morbidity in hospitalized patients receiving human albumin: a meta-analysis of randomized, controlled trials. Crit Care Med 2004;32:2029–38.

10. Szczepiorkowski ZM et al. Apheresis Applications Committee of the American Society for Apheresis. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 2010;25:83–177.

11. Jacob M et al. The intravascular volume effect of Ringer's lactate is below 20%: a prospective study in humans. Crit Care 2012;16:R86.

12. Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. J Hepatol 2012;55:1172–81.

13. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53:397–417.

14. Dellinger RP et al. Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intens Care Med 2013;39:165–228.

15. Haynes GR, Navickis RJ, Wilkes MM. Albumin administration: what is the evidence of clinical benefit? A systematic review of randomized controlled trials. Eur J Anaesthesiol 2003;20:771–3.

16. 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 Aug;18(4):429–37.

17. 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; 144:223–30.

18. Cochran A, Morris SE, Edelman LS, Saffle JR. Burn patient characteristics and outcomes following resuscitation with albumin. Burns 2007;33:25–30.

19. Youssef MA, Al-Inany HG, Evers JL, Aboulghar M. Intra-venous fluids for the prevention of severe ovarian hyperstimulation syndrome. Cochrane Database Syst Rev 2011;16:CD001302.

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