Moving albumin into the small volume resuscitation era

Excerpt

Physicians have an intense 70-year history of enthusiasm, skepticism, fear, and reconciliation with albumin products since their market introduction in the late 1940s [1]. Despite its cumbersome production method and costs, albumin became popular soon after its debut. Advances in its production technique, producing purer formulations with less prekallikrein activators, turned it into a compound with few immediate adverse reactions that appeared to be safe [1]. However, the most recent turbulent episodes of albumin use (still known by most critical care physicians) start with the notorious meta-analysis suggesting harm [2], passes through a redemption clinical trial [3], and lands on more recent studies that may point to a specific direction, but yet provide no conclusive data [4]. There are still several gaps in our knowledge about albumin resuscitation. One of the most pressing questions is whether, given that higher positive fluid balance is associated with worse clinical outcome [5] and that albumin is safe [3], a resuscitation strategy based on hyperoncotic (20%) albumin resuscitation would be useful? If so, which would be the ideal comparator: isoncotic albumin or crystalloids? While comparing 20% albumin to crystalloids would make sense considering the cost of high albumin, one would be left unsure if differences would be due to the presence of albumin by itself or, maybe, due to the side effects of some crystalloids solutions (especially saline), so isoncotic albumin seemed like a rational comparator for a first peek. The first step to answer this question is now discussed in the paper by Mårtensson and coworkers (the SWIPE trial) in a recent article in Intensive Care Medicine [6]. In this well-conducted pilot study, 330 patients (out of an expected 400 patients) from Australia and UK were randomized to receive 20% or 4–5% albumin preparations in the first 48 h after ICU admission. As a result of the study’s pilot nature, the authors were interested in physiological effects and (appropriately) chose cumulative volume of resuscitation fluid as their primary outcome. Rich data on physiological and hemodynamic variables also allow us to obtain a good picture of how the interventions differed. …