When to give and when NOT to give albumin

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When to give and when NOT to give albumin

• Done by Dr.Fahad H. Abduljabbar
• Orthopaedic Resident

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What is albumin?

• Human plasma protein, 66 Kd
• 80 of plasma proteins
• Negatively charged
• Synthesized in the liver
• Degradation is poorly understood

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Functions of albumin?

• Maintenance of the colloid osmotic pressure (COP)
• Binding and transport, particularly of drugs
• Free radical scavenging
• Acid base balance
• Anti-coagulatory effects
• Affects vascular permeability

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Frequency of hypoalbuminemia

• At the time of hospital admission, 20 of
  patients have hypoalbuminemia

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Causes of hypoalbuminemia

• Decreased or abnormal synthesis synthesis.
• hepatitis, CLD, PEM,IBD
• Increased catabolism (major injuries,
  malignancy,fever,pancreatitis)
• Increased loss nephrotic syndrome,burns,gut
  losses,hemorrhage post surgical procedures
• Redistribution Haemodilution (CHF,ARDS,
  overhydration )
• Increased capillary permeability (sepsis, SIRS
  stress response)

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Causes of hypoalbuminemia in crtically ill
patients

• Decreased hepatic production due to chronic
  illness
• Redistribution into the extravascular space
• Dilution due to fluid administration

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Morbidity mortality

• Low serum albumin levels are an important
  predictor of morbidity and mortality. A
  meta-analysis of cohort studies found that, with
  every 10 g/L decrease in serum albumin, mortality
  was increased by 137 and morbidity increased by
  89
• The study also showed increased in ICU stay by
  28 hospital stay by 71
• ________________________________
• from Annals of Surgery
• Posted 03/17/2003
• Jean-Louis Vincent, MD, PhD, FCCM, Marc-Jacques
  Dubois, MD, Roberta J. Navickis, PhD, Mahlon M.
  Wilkes, PhD
• Department of Intensive Care, Université Libre de
  Bruxelles, Hôpital Erasme, Brussels, Belgium, and
  Hygeia Associates, Grass Valley, California,
  U.S.A

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Approach for hypalbuminemia

• HX
• Gather past medical history for a history of
  liver or renal failure, hypothyroidism,
  malignancy, and malabsorption.
• Evaluate the patient for appropriate dietary
  intake.
• Seek potential causes of acute or chronic
  inflammation that could explain the low albumin
  levels

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Examination

• Head, eyes, ears, nose, and throat
• Facial edema, macroglossia, parotid swelling,
  conjunctival icterus, temporal wasting
• Integumentary
• Loss of subcutaneous fat, delayed wound healing,
  dry coarse skin, painful dermatoses, peripheral
  edema, thin hair, spider angiomas, palmar
  erythema, jaundice
• Cardiovascular - Bradycardia, hypotension,
  cardiomegaly

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• Respiratory gynecomastia,signs of pleural
  effusion
• GIT ascitis, hepatosplenomegaly
• Musculoskeletal wasting of mscles
• Neurological asterixis, encephalopathy
• Genitourinary testicualr atrophy

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Lab studies

• Malnutrition Lymphocyte count and BUN are
  decreased. Transferrin, prealbumin, and
  retinol-binding protein have shorter half-lives
  compared with alubmin so it reflects short time
  change of PEM.
• Inflammation CRP ESR are elevated.
• Nephrotic syndrome The 24-hour urine collection
  contains more than 3 g of protein in 24 hours.
• Cirrhosis LFT (transaminase levels) may be
  elevated or normal in patients who are cirrhotic.
  hepatitis screening, may be needed.
• Malabsorption Fecal fat studies including Sudan
  qualitative stain for fat, 72-hour quantitative
  fecal fat collection, and fecal a-1-antitrypsin
  clearance are needed.

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Imaginig studies

• Liver US
• Small bowel series for mucosal abnormalities
• CXR ? Chest infection ass. With pleural effusion
• Echocardiography for CHF

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Other dignostic procedures

• Liver biopsy
• Kidney biopsy

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Treatment

• Should be focused on the underlying cause
• Simply replacing albumin intravenously has
  generally been ineffective

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Indications for albumin admin.

• Indicated
• Following large volume paracentesis
• Nephrotic syndrome resistant to potent diuretics
• Volume/Fluid replacement in plasmapheresis
• Serum albumin lt2.0 g/dl
• Labile pulmonary, cardiovascular status
• Extensive burns ( gt15)
• Plasma exchange
• Intraoperative fluid requirement gt 5-6 L in
  adults
• Premature infant undergoing major surgery

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• Possibly indicated
• Adult respiratory distress syndrome
• Ovarian hyperstimulation syndrome
• Cardiopulmonary bypass pump priming
• Fluid resuscitation in shock/sepsis/burns
• Neonatal kernicterus

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• Not indicated
• Correction of measured hypoalbuminemia or
  hypoproteinemia
• Nutritional deficiency, total parenteral
  nutrition
• Pre-eclampsia
• Red blood cell suspension
• Simple volume expansion (surgery, burns)
• Wound healing

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Contraindicated

• patients who are hypersensitive to albumin
• patients at special risk of developing
  circulatory overload (CHF,renal
  insuffciency,chronic anemia)

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Medical/Legal pitfalls

• Administration of albumin, leading to lower serum
  ionized calcium levels and causing myocardial
  depression
• Fluid overload
• Allergic reactions
• Misdiagnosis of ARDS secondary to pulmonary edema

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Literature review

• Ninety cohort studies fulfilling the inclusion
  criteria were identified
• The total number of patients in the 90 studies
  was 291,433 and the median number of patients per
  study was 281
• Forty-nine of the studies, with 200,413
  patients, representing 69 of the total patient
  population, were published since 1998

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Cohort studies

• Thirty studies involved hospitalized patients in
  general, 11 cardiac surgery, 12 noncardiac
  surgery, and 37 renal dysfunction.
• . The median patient age across all included
  studies was 60 years (range 10-89)
• Forty-one included studies were prospective and
  45 were retrospective.
• Four studies involved both prospective and
  retrospective components.
• Five studies were multicenter investigations.

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• pooled OR for these trials was 2.37 (CI
  2.10-2.68). Thus, the odds of death were
  increased by 137 with each 10-g/L decline in
  serum albumin, and the effect was statistically
  significant
• Similarly, based on pooling within clinical
  indications, statistically significant increases
  in mortality odds of 102, 116, 180, and 148
  were observed for the hospitalization (OR 2.02
  CI 1.52-2.70), cardiac surgery (OR 2.16 CI
  1.47-3.16), noncardiac surgery (OR 2.80 CI
  2.18-3.58), and renal dysfunction (OR 2.48 CI
  2.11-2.91) categories, respectively.

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• Hypoalbuminemia was also an independent predictor
  of morbidity across all studies
• The pooled OR for morbidity among all 18 studies
  assessing this endpoint was 1.89 (CI 1.59-2.24),
  indicating a statistically significant 89
  increase in odds of complications corresponding
  to a 10-g/L reduction in serum albumin.

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• Significant increases in morbidity odds of 178,
  52, 73, and 102 were documented respectively
  among the subsets of studies involving
  hospitalization (OR 2.78 CI 1.30-5.98), cardiac
  surgery (OR 1.52 CI 1.12-2.04), noncardiac
  surgery (OR 1.73 CI 1.67-1.79), and renal
  dysfunction (OR 2.02 CI 1.48-2.74).

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Length stay

• Hypoalbuminemia was a significant independent
  predictor of prolongation in both ICU and
  hospital stay. Length of ICU stay was a subject
  of three included studies.60, 78, 84 The pooled
  OR for ICU stay was 1.28 (CI 1.16-1.40),
  indicating a significant 28 increase in odds for
  prolonged ICU stay per 10-g/L decrement in serum
  albumin.
• OR and CI estimates for prolonged hospital stay
  were available from four included studies.1, 39,
  60, 78 The corresponding pooled OR was 1.71 (CI
  1.33-2.21), revealing a significant
  hypoalbuminemia-related increase of 71 in odds
  of prolonged hospital stay.

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• Controlled Trials
• Nine prospective controlled trials with 535 total
  patients
• The median number of patients per trial was 38
  (range 24-219). Seven of the trials were
  randomized.111, 114-119
• Four trials involved pediatric patients.111-113,
  116 For the adult studies the median patient age
  was 59 years (range 47-71). The median duration
  of follow-up for both adult and pediatric trials
  was 26 days (range 5-150).

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• Pooled morbidity
• the pooled OR for occurrence of one or more
  complications in individual patients was 0.74 (CI
  0.36-1.49). Thus, morbidity was lower among
  albumin recipients, but the effect was not
  statistically significant. The pooled odds ratio
  was similar after exclusion of the two
  nonrandomized trials (OR 0.81 CI
  0.41-1.60).112, 113 There was no evidence of
  publication bias (P .367). Among all control
  group patients, 48 (125/262) experienced one or
  more complications.

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• The effect of surgical procedures on serum
  albumin concentration.
• Chirurgia (Bucur). 2008 Jan-Feb103(1)39-43.
• Alberti LR, Petroianu A, Zac RI, Andrade JC Jr.
• Alfa Institute of Gastroenterology of the
  Hospital of Clinics of the Federal University of
  Minas Gerais, Brazil.
• PURPOSE To assess the effect of surgical trauma
  on serum albumin concentration during the
  immediate postoperative period
• METHODS 200 consecutive adult patients submitted
  to elective major surgeries (Group 1) and to
  medium size surgeries (Group 2) were identified
  according to gender, age and skin color.
• ConclusionThere was a reduction in serum albumin
  in Group 1 (p lt 0.0001) and Group 2 (p lt 0.0001),
  with no difference between gender or skin colors
  for major surgeries. However, women showed a
  lower reduction than men in serum albumin in
  medium-sized surgeries. In medium-sized
  surgeries, black patients had the lowest
  reduction in albuminemia. The greater reduction
  in albuminemia occurred in patients older than 65
  years old

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• Replacement of albumin after abdominal surgery
• K Mahkovic Hergouth1 and L Kompan2
• 1Institute of Oncology, Ljubljana, Slovenia
• 2Clinical Center, Ljubljana, Slovenia
• from 27th International Symposium on Intensive
  Care and Emergency MedicineBrussels, Belgium.
  2730 March 2007
• Critical Care 2007, 11(Suppl 2)P405doi10.1186/cc
  5565.
• Method retrospectively studied 76 successive
  patients operated on in the abdomen at the
  Oncologic Institute in Ljubljana in 1997/98
  (group 1 postoperative hypoalbuminemia treated
  with 20 albumin solution) and in 2000/01 (group
  2 no albumin treatment),
• Conclusion
• In both groups there was very significant drop of
  albumin concentration in the first week after
  surgery . In group 2 albumin concentrations were
  very significantly lower than in group 1 until
  the fifth postoperative day
• The difference diminished after the sixth
  postoperative day
• There was negative correlation between the
  postoperative albumin concentration and the
  duration of surgery
• found no difference in the postoperative
  complication rate (surgical or medical), length
  of stay and mortality between the groups.

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• AIDS Res Hum Retroviruses. 2007
  Oct23(10)1197-200. Links
• Graham SM, Baeten JM, Richardson BA, Wener MH,
  Lavreys L, Mandaliya K, Ndinya-Achola JO,
  Overbaugh J, McClelland RS.
• Department of Medicine, University of Washington,
  Seattle, Washington 98104, USA.
  grahamsm_at_u.washington.edu
• A decrease in albumin of over 10 was associated
  with a 3.5-fold increase in the risk of
  progressing to a CD4 count lt200
• A greater decrease in albumin levels accompanying
  HIV-1 acquisition may be a marker for changes in
  early infection associated with more rapid
  disease progression.

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• Crit Care. 20059(6)649-50.
• Is albumin administration in the acutely ill
  associated with increased mortality?
• Vincent JL, Sakr Y, Reinhart K, Sprung CL,
  Gerlach H, Ranieri VM 'Sepsis Occurrence in
  Acutely Ill Patients' Investigators.
• Department of Intensive Care, Erasme Hospital,
  Free University of Brussels, Route de Lennik 808,
  1070 Brussels, Belgium. jlvincen_at_ulb.ac.be
• METHODS In a cohort, multicenter, observational
  study, all patients admitted to one of the
  participating ICUs between 1 May and 15 May 2002
  were followed up until death, hospital discharge,
  or for 60 days. Patients were classified
  according to whether or not they received albumin
  

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• RESULTS
• Of 3,147 admitted patients, 354 (11.2) received
  albumin and 2,793 (88.8) did not. Patients who
  received albumin were more likely to have cancer
  or liver cirrhosis, to be surgical admissions,
  and to have sepsis. They had a longer length of
  ICU stay and a higher mortality rate, but were
  also more severely ill, as manifested by higher
  simplified acute physiology score (SAPS)
• ICU and hospital mortality rates were higher in
  the patients who had received albumin than in
  those who had not (34.8 versus 20.9 and 41.3
  versus 27.7, respectively,

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• Conclusion
• Albumin administration was associated with
  decreased survival in this population of acutely
  ill patients. Further prospective randomized
  controlled trials are needed to examine the
  effects of albumin administration in sub-groups
  of acutely ill patients.

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• Cochrane Database Syst Rev. 2000(2)CD001208.
  Links
• Cochrane Database Syst Rev. 2002(1)CD001208.
• Human albumin solution for resuscitation and
  volume expansion in critically ill patients.
• Bunn F, Lefebvre C, Li Wan Po A, Li L, Roberts I,
  Schierhout G.
• Department of Epidemiology, Institute of Child
  Health, 30 Guilford Street, London, UK, WC1N 1EH.
  Ian.roberts_at_ich.ucl.ac.uk
• Cohort study
• CONCLUSIONS
• There is no evidence that albumin administration
  reduces the risk of death in critically ill
  patients with hypovolaemia, burns or
  hypoalbuminaemia, and a strong suggestion that it
  may increase the risk of death.

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Take home message

• Low serum albumin is an independent indicator of
  (poor) outcome in critical illness.
• There is no evidence that correcting
  hypoalbuminemia improves outcome, indeed
  therapeutic albumin administration may worsen
  outcome.
• Morbidity, mortality and length of stay were not
  influenced by albumin replacement.
• The use of albumin in the critically ill patient
  is not supported by scientific evidence.
• It is no more effective than other agents used in
  the treatment of hypovolaemia.

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• treatment of hypoalbuminaemia has no significant
  benefit. Efforts should be concentrated on
  correcting the underlying cause of disease to
  reverse hypoalbuminaemia.
• The use of albumin may cause death.
• The use of albumin without an indication is a
  waste for the resources

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