‘This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2004, Issue 4. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.’ Roberts, I., Alderson, P., Bunn, F., Chinnock, P., Ker, K., Schierhout, G. 'Colloids versus crystalloids for fluid resuscitation in critically ill patients' Cochrane Database of Systematic Reviews 2004 (4) CD000567. DOI:10.1002/14651858.CD000567.pub2

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Colloids versus crystalloids for fluid resuscitation in critically ill patients

Objective: To quantify effect on mortality of administering human albumin or plasma protein fraction during management of critically ill patients. Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. Subjects: 30 randomised controlled trials including 1419 randomised patients. Main outcome measure:Mortality from all causes at end of follow up for each trial. Results: For each patient category the risk of death in the albumin treated group was higher than in the comparison group.For hypovolaemia the relative risk of death after albuminadministration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19),and for hypoalbuminaemia it was 1.69 (1.07 to 2.67). Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death
with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. Conclusions: There is no evidence that albumin administration reduces mortality incritically ill patients with hypovolaemia,burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.

https://www.bmj.com/content/bmj/317/7153/235.full.pdf

Cochrane Injuries Group Albumin ReviewersWhy albumin may not work

Objective: To quantify effect on mortality of administering human albumin or plasma protein fraction during management of critically ill patients. Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. Subjects: 30 randomised controlled trials including 1419 randomised patients. Main outcome measure: Mortality from all causes at end of follow up for each trial. Results: For each patient category the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death after albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia it was 1.69 (1.07 to 2.67). Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.

Human albumin administration in critically ill patients: systematic review of randomised controlled trials

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)04211-2.pdf

Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study

https://www.jvascsurg.org/article/S0741-5214(11)01635-1/pdf

Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease

• Intimal hyperplasia is a common cause of the narrowing and failure of vein grafts in arterial circuits. Various factors may contribute to this. An experimental dog model that isolated the contribution of blood velocity from other possible causes was developed. Intimal hyperplasia was clearly greater in those segments of vein grafts with low-flow velocities. (Arch Surg115:332-335, 1980)

https://jamanetwork.com/journals/SURG/articlepdf/586133/archsurg_115_3_019.pdf

Intimal Hyperplasia: An Experimental Study

Radiation-induced carotid artery disease following high-dose (greater than 50-Gy) radiotherapy for head and neck cancer may become more common as improved treatment results in longer survival. Duplex ultrasound scans were obtained in 91 consecutive patients to determine whether increased incidence and severity of extracranial carotid disease correlate with prior radiotherapy. Fifty-three patients who underwent radiotherapy an average of 28 months previously and 38 patients who received no radiotherapy were studied. Thirty percent of the irradiated group had lesions of the carotid arteries that were either moderate or severe vs only 6% of the control patients. Five patients were symptomatic; all had undergone radiotherapy. Long-term follow-up with sequential duplex ultrasound examinations is indicated in patients receiving high-dose radiotherapy for head and neck tumors, to detect radiation-induced carotid artery disease and prevent late sequelae.

Duplex imaging and incidence of carotid radiation injury after high-dose radiotherapy for tumors of the head and neck.

• 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/Pao 2 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. (Arch Surg 113:387-392, 1978)

Pulmonary effects of albumin resuscitation for severe hypovolemic shock.

Albumin, when added to a standard resuscitation regimen, is purported to enhance plasma volume, improve pulmonary function by its oncotic effect, and prevent renal failure by augmenting salt and water excreation. These factors were evaluated in a prospective randomized manner in 52 injured patients

Effects of albumin versus non-albumin resuscitation on plasma volume and renal excretory function.

The effects of albumin supplementation on pulmonary function were studied in 94 injured patients of whom 46 received albumin. The 94 patients received an average of 14.5 transfusions, 9.2 L crystalloid, and 0.9 L plasma in the emergency room and operating room; 46 patients received an average of 31 gm albumin during operation and 150 gm/day for 5 days. Blood pressure (BP), pulse, CVP, wedge pressure (PWP), red cell (RBCV), and plasma volumes (PV), total serum proteins (TSP), serum albumin (SA), cardiac output (CO), the per cent inspired oxygen/arterial O2 tension (FIO2/pO2), and the per cent of physiologic shunting in the lungs (p shunt) were noted serially following operation; only the first study on each patient was used for statistical correlations between the two groups. Albumin supplementation significantly (p =

Roger F. Higgins

Papers

Intimal Hyperplasia: An Experimental Study

Duplex imaging and incidence of carotid radiation injury after high-dose radiotherapy for tumors of the head and neck.

Pulmonary effects of albumin resuscitation for severe hypovolemic shock.

Effects of albumin versus non-albumin resuscitation on plasma volume and renal excretory function.

Impaired pulmonary function after albumin resuscitation from shock.