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Human albumin: cardiac surgery

index increased significantly compared to preoperative level, however, HES solutions increased cardiac index slightly more than did albumin.

Navickis et al have published meta- analysis compared use of HES solutions to albumin: haemodynamics was similar in both groups, but the use of albumin decreased blood loss, amount of blood products transfusions and need for reoperation postoperatively.16


This 'platelet preservation' effect of albumin has been discussed in several forums, however, the mechanisms of this effect are still unclear. Some studies reported slight hypocoagulation after albumin use, but these changes are caused more by haemodilution effect. Based on these findings, the use of albumin solution after cardiac surgery is safe also in those patients wh0 already have increased blood loss. The meta- analysis of controlled studies published in 2004 included 1346 patients and compared the use of albumin to crystalloid solution for the CPB priming. Albumin prime preserved platelet counts better than crystalloid, and favourably influenced colloid oncotic pressure and positive fluid balance after cardiac surgery.17 Because of its biological origin, albumin has multiple functions. It is possible that albumin coats from inside the tubes and reservoir of CPB circuit and therefore reduces contact activation of leucocytes and platelets, which occurs during CPB. Jacob et al reported that albumin also has a protective effect on the endothelial glycocalix, which is damaged during CPB.8

this meta-analysis has insufficient data about the use of tetrastarch HES130/0.4. Some investigators reported a very interesting fact: when the use of albumin solution was compared to other colloids with non-biological origin or to crystalloids, the platelet count in the albumin group were significantly higher postoperatively then in the other fluids group.13

At this time, debates about volume replacement therapy are at the top of scientific discussion. Some countries stopped the use of synthetic colloids because of the results of a few studies in the critically ill patients, which demonstrated that HES solutions probably impair renal function and even outcome.18

Despite the fact that the 20

conclusions to these studies are questionable and their results are impossible to extrapolate to the surgical patients, the fact is that more and more

hospitals have abandoned the use of synthetic colloids until such time as they receive new data about their safety in patients scheduled for surgical procedures. More and more hospitals use only crystalloids, even for volume

replacement, which leads to the increased amount of fluids given. Because the degree of systemic inflammatory response reaction and damage of endothelial glycocalix after cardiac surgery is high, and patients often have a lot of co- morbidities, the use of pure crystalloid volume replacement is possibly not justified. Use of albumin solution should be considered for volume replacement

cardiopulmonary bypass. J Thromb Thrombolysis 2003;16(3):129–47.

6. Despotis GJ, Avidan MS, Hogue CW. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001 Nov;72(5):S1821–31.

7. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2013;2:000567.

8. Jacob M et al. Albumin augmentation improves condition of guinea pig hearts after 4 hr of cold ischemia. Transplantation 2009;87(7):956–65.

9. Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a

"It is possible that albumin coats from inside the tubes and reservoir of CPB circuit and therefore reduces contact activation of leucocytes and platelets, which occurs during CPB"

during or after cardiac surgery, at least in those patients at risk of bleeding or renal dysfunction. Albumin solution provides good haemodynamic effect which lasts several hours without any clinically significant side-effects. In those special cases when patients are already fluid overloaded (for example, emergency surgery or transplantation patients), the use of small amounts of hyperoncotic albumin solution should be considered. In the field of cardiac surgery, only data from small prospective randomised studies compared albumin to crystalloids or other colloids. The big multicentre studies investigating albumin solution after cardiac surgery are welcome and, hopefully, after results of these studies are known, we will have the possibility of further improving our volume replacement therapy. l

References 1. Chappell D et al. A rational approach to perioperative fluid management. Anesthesiology 2008;109(4):723–40.

2. Rehm M et al. Shedding of the endothelial glycocalyx in patients undergoing major vascular surgery with global and regional ischemia. Circulation 2007;116(17):1896–1906.

3. Boisclair MD et al. Mechanisms of thrombin generation during surgery and cardiopulmonary bypass. Blood 1993;82(11):3350–7.

4. Edmunds LH,Jr, Colman RW. Thrombin during cardiopulmonary bypass. Ann Thorac Surg 2006;82(6):2315–22.

5. Linden MD. The hemostatic defect of

randomized assessor-blinded multicenter trial. Ann Surg 2003;238(5):641–8.

10. Egelman DT et al. Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg 1999;118:866–73.

11. Fritz HG et al. Post-operative hypoalbuminaemia and procalcitonin elevation for prediction of outcome in cardiopulmonary bypass surgery. Acta Anaesthesiol Scand 2003;47(10):1276–83.

12. Sedrakyan A et al. Volume expansion with albumin decreases mortality after coronary artery bypass graft surgery. Chest 2003;123:1853–7.

13. Onorati F et al. Does priming implementation with low-dose albumin reduce postoperative bleeding following cardiopulmonary bypass? Int J Artif Organs 2003;26(3):211–6.

14. Niemi TT et al. Gelatin and hydroxyethyl starch, but not albumin, impair hemostasis after cardiac surgery. Anesth Analg 2006;102(4):998–1006.

15. Schramko AA et al. Rapidly degradable hydroxyethyl starch solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Anesth Analg 2009;108(1):30–6.

16. 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(1):223–30.

17. 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;18(4):429–37.

18. Myburgh JA et al. The CHEST Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Hydroxyethyl Starch or Saline for Fluid Resuscitation in Intensive Care. N Engl J Med 2012;Oct 17.

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