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Human albumin: cardiac surgery

Human albumin: advantages in cardiac surgery

In surgical patients, fluid overload, as caused by crystalloids, has been demonstrated to be an independent risk factor for morbidity and mortality. The benefits of the use of human albumin are here discussed

Alexey Schramko MD Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Finland alexey.schramko@hus.fl

During cardiac surgery, large fluid transfers, priming of cardiopulmonary bypass (CPB) circuit and blood and blood products transfusions, as well as long surgery time, lead almost always to fluid overload. Despite the large amount of fluids administered, patients who have had CPB often have blood volume deficit because of fluid shift from intra- to extravascular space due to systemic inflammatory response and damage of endothelial glycocalix.1

The fluid 'leakage'

after cardiac surgery lasts for between several hours and several days.2 Conversely, haemodynamics after cardiac surgery is often affected. The phenomenon of myocardial stunning is described widely and, in the early postoperative period, a significant number of patients need inotropic support and/or vasopressors because of the reversible acute heart failure. Additionally, the majority of patients postoperatively need more intravascular volume for cardiac output optimisation.

Coagulation disturbances CPB impairs blood coagulation and, in some cases, renal function. There are several mechanisms of coagulation disturbances during CPB. The contact pathway is triggered when factor XII, prekallikrein and high molecular weight kininogen interface with nonbiological surfaces of the CPB circuit.3

18 coagulation pathway is triggered when

"Albumin solution provides good haemodynamic effect which lasts several hours without any clinically significant side-effects"

factor VIIa complexes with tissue factor being expressed on leucocytes, platelets or exposed subendothelium within the vessel wall. Therefore, thrombin generation increases strongly.4

On the

other hand, CPB initiation leads to the decrease of coagulation factors (partially, due to haemodilution) and increases the fibrinolytic activity.5

The incidence of The extrinsic

severe bleeding in cardiac surgery exceeds 10%, and approximately 5–7% of patients experience blood loss in excess of 2L within the initial 24h postoperatively.6 After CPB, patients are predisposed to different complications, and the discovery of optimal conditions is challenging. The

optimal volume resuscitation after CPB should be performed using small amounts of fluid, which stay at least several hours intravascularly without undesirable side effects.

Different solutions, both crystalloids and colloids, have been used for volume replacement after cardiac surgery. A Cochrane systematic review did not find any difference in major outcomes when colloids have been compared to crystalloids.7

Crystalloids do not have

significant side-effects apart from haemodilution, but their volume effect is low (about 20%) and they stay in the intravascular space for a very short time,

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