The evidence for small-volume resuscitation with hyperoncotic albumin in critical illness

John A Myburgh

doi:10.1186/cc6882

John A Myburgh

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https://doi.org/10.1186/cc6882

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Small-volume resuscitation of critically ill patients with hyperoncotic albumin offers a number of theoretical advantages, such as increasing intravascular volume in excess of the volume of fluid administered and reducing interstitial edema. Whilst iso-oncotic albumin has been shown to be equi-effective to isotonic saline for the resuscitation of critically ill patients without associated traumatic brain injury, the efficacy of hyperoncotic albumin for resuscitation has not been evaluated in large-scale randomized-controlled trials. Overall, the evidence for resuscitation with hyper-oncotic albumin is limited by studies of poor methodological quality with heterogenous study populations and control regimens. There is marginal qualitative evidence of improvements in surrogate outcomes in disparate patient populations, but no evidence of any survival benefit associated with resuscitation with hyperoncotic albumin. Given the lack of evidence and clinical uncertainty about the efficacy of hyperoncotic albumin, a large-scale randomized-controlled trial is required to determine its role in the acute resuscitation of hypovolemic or hypoalbuminemic critically ill patients.

Highlights

Hypertonic crystalloids, such as saline, have been advocated for small-volume resuscitation, in the pre-hospital setting
Albumin has been used for resuscitation since the 1940s, primarily for acute resuscitation in hypovolemic patients, and for ‘slow’ resuscitation in hypoalbuminemic patients with liver disease undergoing abdominal paracentesis
Despite limited evidence for the use of hyperoncotic albumin in these contexts, unequivocal evidence for the efficacy of iso-oncotic (4%) albumin for resuscitation of patients in the intensive care unit exists following the publication of the Saline versus Albumin Fluid Evaluation (SAFE) study [4]

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Introduction

Hypertonic crystalloids, such as saline, have been advocated for small-volume resuscitation, in the pre-hospital setting. Under time-critical conditions such as traumatic brain injury, burns or severe sepsis, resuscitation with small volumes of hyperoncotic fluid appear attractive, in the pre-hospital setting where prompt delivery of smaller volumes of resuscitation solutions may be more effectively administered.

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