hydroxyethyl starch FDA warning

[urge]

FYI

Boxed Warning on increased mortality and severe renal injury, and additional warning on risk of bleeding...

http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ucm358271.htm

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Members don't see this ad.

 

[WholeLottaGame7]

FYI


http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ucm358271.htm

And yet, last month in the SICU, we'd still have patients coming from the OR having received 1500 of voluven....

 

[TrustMe]

I stopped using all starches on sick patients a couple of years ago. When I was a fellow we had a Voluven rep that got the hospital to get it on formulary and even stocked in our OR's. Then when everyone figured out that the data was sketchy the hospital immediately dropped it.

I still use hespan occasionally, but if it's a big case or the patient is sick I stick with crystalloid and albumin. Even after the article a couple months ago I am surprised that the FDA jumped in this quick.

 

[Jay K]

As an aside, I recently heard about the use of hespan drips post-op for volume and anticoagulant effect to keep flaps alive.

 

[IveGotTwins]

For those of you who routinely avoid starches, do you do so for all patients or for those who are coming from ICU with multiple issues regarding bleeding/coagulation or renal dysfunction?

 

[Idiopathic]

As an aside, I recently heard about the use of hespan drips post-op for volume and anticoagulant effect to keep flaps alive.

ive seen this with dextran but yes this seems to be fairly common

 

[Idiopathic]

For those of you who routinely avoid starches, do you do so for all patients or for those who are coming from ICU with multiple issues regarding bleeding/coagulation or renal dysfunction?

i havent given it in over 2 years, i think its risky and there are other options

 

[Mr Wizard]

i havent given it in over 2 years, i think its risky and there are other options

I definitely think it is risky in higher acuity patients/cases. The trauma and ICU cases have pretty strong data on risk. I feel like it probably extends to more patients at risk after reading about the believed pathophysiology of the renal damage.

I also doubt that following recommend volume, it is harmful to healthier patients. Some places do not do have readily available alternatives like albumin so I think there probably is a niche for them.

 

[BLADEMDA]

I've switched to Albumin and LR after this warning. I prefer that my O.R. remove all Hextend and Hespan immediately. I do not want any CRNA to administer them.

 

[bigdan]

A few of our hospitals in the UPMC hospital system here in Pittsburgh have removed them entirely.

 

[G0S2]

I think we have to keep in mind the context of the large study in the NEJM.

1.) The patients were in septic shock

2.) the dose of starch was 44 ml per kilogram


I sill occasionally give 500cc to a huge bowel whack case with a normal HCT and evidence of continued hypovolemia after Plasmalyte. Many times I notice the SSV reduce nicely.

 

[BLADEMDA]

I think we have to keep in mind the context of the large study in the NEJM.

1.) The patients were in septic shock

2.) the dose of starch was 44 ml per kilogram


I sill occasionally give 500cc to a huge bowel whack case with a normal HCT and evidence of continued hypovolemia after Plasmalyte. Many times I notice the SSV reduce nicely.

I've been using starch solutions since the 1990s. I now use albumin and LR or plasmalyte.
The SVV will reduce nicely with them as well.

I think the risk/reward does not justify the use of this product any longer. Just say no to Hextend.

The last few years I was only giving 1 bag of hextend. No longer. I now think there is simply no reason to use this type of product when we have safer volume expanders readily available.

 

[urge]

I think we have to keep in mind the context of the large study in the NEJM.

1.) The patients were in septic shock

2.) the dose of starch was 44 ml per kilogram


I sill occasionally give 500cc to a huge bowel whack case with a normal HCT and evidence of continued hypovolemia after Plasmalyte. Many times I notice the SSV reduce nicely.

I have always had problems with this logic: "We can get away with something that is probably bad, the patient is healthy and can tolerate a small hit." The healthy ones don't really need any special interventions. They will be fine with whatever you do. Either 500ml of HES or 1.5L of LR (assuming you believe in the 3:1). Can you imagine if the Voluven rep went to your hospital now saying: "it is great just for your healthy patients, the sick ones will probably not survive it!"

I just don't see the benefit in saving 1L form your I:O's.

1L of crystalloid vs. a FDA warning, with which the lawyers will have a field day? It's not rocket science.

 

[OB1🤙]

I stay far, far away from this stuff.

Risk>>benefit IMO.

 

[IveGotTwins]

I have one attending who uses voluven as his primary IV fluid. Literally straight to it. Day surgery, in house, ICU, whatever. As a fresh CA-1 I thought it was strange since no one else did so but now as a fresh CA-2 I think it's probably wrong. The only time I use starches are for open belly cases where the they have been receiving generous amounts of crystalloid in the unit/step-down assuming no on-going renal/coagulation issues and I need a volume expander but not blood product. I also will use them for prone cases that go on forever. After one liter LR/NS I switch to colloid. I try to give as minimal amounts of fluid for these situations anyway. Anyone have a good strategy to avoid the Jabba the Hut face when going prone for several hours besides minimizing fluids altogether?

 

[BLADEMDA]

I have one attending who uses voluven as his primary IV fluid. Literally straight to it. Day surgery, in house, ICU, whatever. As a fresh CA-1 I thought it was strange since no one else did so but now as a fresh CA-2 I think it's probably wrong. The only time I use starches are for open belly cases where the they have been receiving generous amounts of crystalloid in the unit/step-down assuming no on-going renal/coagulation issues and I need a volume expander but not blood product. I also will use them for prone cases that go on forever. After one liter LR/NS I switch to colloid. I try to give as minimal amounts of fluid for these situations anyway. Anyone have a good strategy to avoid the Jabba the Hut face when going prone for several hours besides minimizing fluids altogether?

I like to use some albumin for my bigger cases. While I realize the data on better outcome vs LR or plasmalyte isn't there I believe limiting the amount of third spacing due to large amounts of crystalloid makes the expense of albumin worth it.

 

[urge]

I have one attending who uses voluven as his primary IV fluid. Literally straight to it. Day surgery, in house, ICU, whatever. As a fresh CA-1 I thought it was strange since no one else did ....

Did he train in Germany? Those guys use that like water. Wonder if they are changing their practices based on this warning.

Did you guys get the email from voluven? They must be scared.

 

[dhb]

What i don't understand is people are now saying "well now i'm just using albumin instead". What's the data on albumin? i've never used voluven never used albumin (except for liver patients) and very rarely use a gelatin as a temporazing measure when i'm waiting for blood products.

I think i'ts sad to see complete disregard to physiology and fluid management by MDs: or the patient is hypovolemic and needs cristalloids or he's vasoplegic and needs vasopressors i don't see where colloids fit in this picture.

 

[urge]

What i don't understand is people are now saying "well now i'm just using albumin instead". What's the data on albumin? i've never used voluven never used albumin (except for liver patients) and very rarely use a gelatin as a temporazing measure when i'm waiting for blood products.

I think i'ts sad to see complete disregard to physiology and fluid management by MDs: or the patient is hypovolemic and needs cristalloids or he's vasoplegic and needs vasopressors i don't see where colloids fit in this picture.

There is a huge paper on albumin being inferior to crystalloid in traumatic brain injury. Look it up.

There is smaller evidence about benefit in hypoalbuminemic patients.

 

[Mman]

What i don't understand is people are now saying "well now i'm just using albumin instead". What's the data on albumin? i've never used voluven never used albumin (except for liver patients) and very rarely use a gelatin as a temporazing measure when i'm waiting for blood products.

I think i'ts sad to see complete disregard to physiology and fluid management by MDs: or the patient is hypovolemic and needs cristalloids or he's vasoplegic and needs vasopressors i don't see where colloids fit in this picture.

and what about in a pneumonectomy patient that is hypovolemic and might not tolerate much crystalloid at all without developing pulmonary edema?

 

[BLADEMDA]

Crit Care Med. 2011 Feb;39(2):386-91. doi: 10.1097/CCM.0b013e3181ffe217.
The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis.
Delaney AP, Dan A, McCaffrey J, Finfer S.
Source
Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia. [email protected]
Abstract
OBJECTIVE:
To assess whether resuscitation with albumin-containing solutions, compared with other fluids, is associated with lower mortality in patients with sepsis.
DATA SOURCES:
MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases, the metaRegister of Controlled Trials, and the Medical Editors Trial Amnesty Register.
STUDY SELECTION:
Prospective randomized clinical trials of fluid resuscitation with albumin-containing solutions compared with other fluid resuscitation regimens, which included a population or subgroup of participants with sepsis, were included.
DATA EXTRACTION:
Assessment of the validity of included studies and data extraction were conducted independently by two authors.
DATA SYNTHESIS:
For the primary analysis, the effect of albumin-containing solutions on all-cause mortality was assessed by using a fixed-effect meta-analysis.
RESULTS:
Seventeen studies that randomized 1977 participants were included in the meta-analysis. There were eight studies that included only patients with sepsis and nine where patients with sepsis were a subgroup of the study population. There was no evidence of heterogeneity, I² = 0%. The use of albumin for resuscitation of patients with sepsis was associated with a reduction in mortality with the pooled estimate of the odds ratio of 0.82 (95% confidence limits 0.67-1.0, p = .047).
CONCLUSIONS:
In this meta-analysis, the use of albumin-containing solutions for the resuscitation of patients with sepsis was associated with lower mortality compared with other fluid resuscitation regimens. Until the results of ongoing randomized controlled trials are known, clinicians should consider the use of albumin-containing solutions for the resuscitation of patients with sepsis.
Comment in
Does resuscitation with albumin-containing solutions improve mortality in sepsis? [Ann Emerg Med. 2012]
Does albumin fluid resuscitation in sepsis save lives? [Crit Care Med. 2011]
Albumin meta-analysis and epochs of care. [Crit Care Med. 2011]
PMID: 21248514 [PubMed - indexed for MEDLINE]
Publication Types, MeSH Terms, Substances

LinkOut - more resources

 

[BLADEMDA]

10 SAFE Study Investigators. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med 2011;37:86-96.
11 Caironi P, Gattinoni L. The clinical use of albumin: the point of view of a specialist in intensive care. Blood Transfus 2009;7:259-267.
12McIntyre L, Fergusson DA, Rowe B, Cook DJ, Arabi Y, Bagshaw SM, Emond M, Finfer S, Fox- Robichaud A, Gray A, Green R, Hebert P, Lang E, Marshall J, Stiell I, Tinmouth A, Pagliarello J, Turgeon A, Walsh T, Worster A, Zarychanski R. The PRECISE RCT: Evolution of an Early Septic Shock Fluid Resuscitation Trial. Transfus Med Rev doi:10.1016/j.tmrv.2011.11.003.

 

[BLADEMDA]

http://www.grifolsusa.com/portal/en...ml?div=8883&fam=14766&subfam=null&prod=342868

I used a ton of this stuff in the 1990s. Anyone still using plasmanate? Should I be using this (once again) instead of albumin?

In Residency I once gave 5,000 mls of plasmanate to a patient over 12 hours.

 

[BLADEMDA]

Do any of you always dilute the 25 percent albumin with LR or Saline prior to administration? Do most prefer and use the 5 percent albumin over the 25 percent version?

 

[urge]

I like the 25% stuff straight on anasarcic (anasarkic?) but hypo volemic patients. I figure they already have enough volume. Just not in the right place. On normal looking patients I use 5% or dilute 25%.

 

[pie944]

There is a huge paper on albumin being superior to crystalloid in traumatic brain injury. Look it up.

That increase in mortality is what I look for in a fluid.

 

[urge]

That increase in mortality is what I look for in a fluid.

My apologies. I got it backwards. Thanks for pointing it out.

Thank God I don't do neuro.

 

[Idiopathic]

Do any of you always dilute the 25 percent albumin with LR or Saline prior to administration? Do most prefer and use the 5 percent albumin over the 25 percent version?

love 25% when i feel like the patient isnt extremely underresuscitated, as i feel that it really does rely on capturing excess interstitial fluid for its benefit

i do not dilute it

 

[pie944]

Do any of you always dilute the 25 percent albumin with LR or Saline prior to administration? Do most prefer and use the 5 percent albumin over the 25 percent version?

5% albumin has an oncotic pressure of around 20 mmHg. Human plasma oncotic pressure is between 20-25 mmHg give or take. So 5% won't have any pull effect from the interstitial side, if that is a goal 25% should be used.

 

[pie944]

My apologies. I got it backwards. Thanks for pointing it out.

Thank God I don't do neuro.

Wasn't making fun, sorry. Just presumed sarcasm on your part and I always cherish the chance to further a sarcastic post.

 

[dhb]

and what about in a pneumonectomy patient that is hypovolemic and might not tolerate much crystalloid at all without developing pulmonary edema?

There are some exceptions, in this case it's probably more a heart problem than a fluid problem.

 

[BLADEMDA]

There are some exceptions, in this case it's probably more a heart problem than a fluid problem.

There are many European proponents in the use of Albumin. I'm not advocating its routine use in most cases. That said, in certain cases and procedures with massive fluid shifts albumin has a role to play

 

[Mman]

There are some exceptions, in this case it's probably more a heart problem than a fluid problem.

but I'm questioning what fluid you'd use. Colloids work great in those patients. Albumin is nice, but does carry some infectious risk as it's purified from human donors. If we start giving it out like candy we will see more of those problems.

In my mind if you aren't septic and aren't a critically ill trauma/cardiac patient colloids can be beneficial in fluid management when used appropriately. There are several places with fast track colorectal surgery programs that have shorter hospital length of stay and lower morbidity for patients with a decent use of colloids intraop. Don't throw the baby out with the bathwater.

 

[dhb]

There are several places with fast track colorectal surgery programs that have shorter hospital length of stay and lower morbidity for patients with a decent use of colloids intraop. Don't throw the baby out with the bathwater.

Even with an average surgeon a left sided colectomy is going to be a 3h case during which i'll administer approximately 3l of cristalloids. If I were to give a colloid it would end up being 1 or 2L of cristalloids and 500ml of colloids: i don't think this 500ml-1L saving has any clinical significance.

I don't say colloids are totally unnecessary but i just think they have a very limited use and are probably primarily used to counter vasoplegia which would be better addressed by a vasoconstrictor.

 

[BLADEMDA]

In this meta-analysis, the use of albumin-containing solutions for the resuscitation of patients with sepsis was associated with lower mortality compared with other fluid resuscitation regimens. Until the results of ongoing randomized controlled trials are known, clinicians should consider the use of albumin-containing solutions for the resuscitation of patients with sepsis.

 

[pie944]

In this meta-analysis, the use of albumin-containing solutions for the resuscitation of patients with sepsis was associated wh lower mortality compared with other fluid resuscitation regimens. Until the results of ongoing randomized controlled trials are known, clinicians should consider the use of albumin-containing solutions for the resuscitation of patients with sepsis.

Discussing a meta analysis is valuable and imports tool, but posting the conclusion without discussing the trials it utilized and the details of those trials can be very misleading. There are meta-analysis for steroids/septic shock that show mortality benefit and others that do not, one needs to analyze the details of these studies not just the summary.

 

[BLADEMDA]

We’re frustrated about the starch situation because every time a range of starch products exhibits adverse events, the companies modify the molecule. They do not withdraw the previous generation from the market and neither do the regulators. Albumin is a natural molecule and it’s not amenable to the same kind of modification as the synthetic colloids. We are using a cost-effectiveness model comparing starch to albumin in the ICU sepsis environment, and the results are going to be very interesting. We can show, using evidence-based parameters, that albumin will be cost-effective in this environment

http://www.cslbehring.com/docs/399/381/Albumin_FINAL,1.pdf

Take 5 minutes and read the above link. You may learn a thing or two

 

[pie944]

We’re frustrated about the starch situation because every time a range of starch products exhibits adverse events, the companies modify the molecule. They do not withdraw the previous generation from the market and neither do the regulators. Albumin is a natural molecule and it’s not amenable to the same kind of modification as the synthetic colloids. We are using a cost-effectiveness model comparing starch to albumin in the ICU sepsis environment, and the results are going to be very interesting. We can show, using evidence-based parameters, that albumin will be cost-effective in this environment

http://www.cslbehring.com/docs/399/381/Albumin_FINAL,1.pdf

Take 5 minutes and read the above link. You may learn a thing or two

I use albumin, I don't want to seem like someone who is against it. I think there is a role for it in fluid management.

This article you posted is from the website of a company that produces albumin, it is a question answer paper with multiple physicians answering questions about albumin sponsored by the company. Do you really think this is quality objective evidence? Even though I agree with some of the points, is this how one wants to make their evidenced based decision? A question answer from the makers of the product you are attempting to use? I'll let the individuals of this forum decide how that rates for evidence.

Evidenced based medicine is not easy to practice by, it is very difficult to accomplish on one issue let alone a multitude of management issues. I think anyone who has ever been to a journal club can attest to how what can appear to be a fantastic study is easily picked apart. One cannot make their management decisions based on a single meta-analysis, a question and answer, or even a single randomized control study without truly investigating the details of not only the single study, but the entire spectrum of evidence on that issue. In order to make appropriate medical decisions based on evidence based medicine one needs to look at the totality of the evidence on that specific subject.

There is a recent study in the NEJM(N Engl J Med 2013;368:2159-68,RCT, multicenter, etc) on prone positioning with the results summary as the following

"A total of 237 patients were assigned to the prone group, and 229 patients were assigned
to the supine group. The 28-day mortality was 16.0% in the prone group and
32.8% in the supine group (P<0.001). The hazard ratio for death with prone positioning
was 0.39 (95% confidence interval [CI], 0.25 to 0.63). Unadjusted 90-day mortality
was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a
hazard ratio of 0.44 (95% CI, 0.29 to 0.67). The incidence of complications did not
differ significantly between the groups, except for the incidence of cardiac arrests,
which was higher in the supine group." (N Engl J Med 2013;368:2159-68.)

So should we prone all our patients with ARDS? Do we look at one impressive RCT that has a very significant finding? Do we look at the multiple prior trials? How do all the trials compare in terms of the severity of ARDS, the timing of prone positioning, the duration, the way the prone group was turned?

This type of questioning should be utilized by any individual discussing the current evidence on a specific issue, including albumin. It isn't easy.

I think posting this link, or any link without discussing it is doing a disservice to the medical students and residents who might be reading this thread and then going to rounds the next day and citing this as their evidence.

 

[BLADEMDA]

GARY HAYNE S : There is a need to educate healthcare providers about albumin
because its use has changed over time and is still controversial. Even some of the
literature for volume resuscitation isn't up-to-date because we have better ways of
assessing intravascular volume. Many older studies indicate dosage to meet some
endpoint, such as central venous pressure, which no longer is regarded as the best
way to assess intravascular volume. But people still doubt the value of albumin in
conditions such as resuscitation. Some have been driven by economics to question the
benefits of albumin, leading them to emphasize the use of crystalloids in resuscitation.
The effectiveness and role of crystalloid has yet to be demonstrated versus copious
evidence that albumin does more than just maintain colloid oncotic pressure.


GARY: A central problem in the US is that we don't know the cost of treating a
disease. When it comes to albumin, we've selected unsatisfactory endpoints in the
past. When you do meta-analyses, it all rolls out to a global outcome, such as whether
the patient lives or dies. But if you pick better clinically important endpoints, such as
the length of time the patient is on a ventilator in the ICU or their length of stay, you
will have a more convincing argument. Much of the literature favors what's least
expensive without looking at these outcomes. Much of the resuscitation literature
presents a grossly oversimplified view of the problem.

 

[BLADEMDA]

MAURO: No. But since you mention Professor Boldt, I’ll tell you an interesting thing
about those meta-analyses. When you take the studies of Dr. Boldt out of the
Delaney3, Cochrane4 or Zakarinski5 meta-analyses for HES effects on renal functon,
it has an amazing effect on the odds ratio. Delaney already reports an 18 percent
improvement in mortality rate with albumin across the whole meta-analysis, but when
you extract the Boldt studies, the improvement in mortality rate goes up to 26 percent.
And when you remove the Boldt studies, including the retracted studies from those
meta-analyses on renal complications, HES looks very bad.

 

[BLADEMDA]

I found the discussion of Albumin and HES by these world experts quite informative. They touched on hundreds of issues in that discussion. But, the take away point was very clear:


LUC IANO: Starch is dead. You’re really making a comparison with crystalloid. It’s a
question of the market and so on, but from the medical point of view, to use starch is
wrong. It’s not good medicine. That means it’s also bad economics

 

[BLADEMDA]

Anecdotally, with large volume shifts (trauma, tumors, etc) where EBL can be significant I think the 25% Albumin can help in reducing postop edema especially around the face/neck. This means I am more likely to extubate the patient in the PACU rather than the next day.
My N=1 so far and I think it made the difference in avoiding the ventilator overnight.

 

[BLADEMDA]

Very Scant Literature on the use of 20-25% Albumin in surgical cases needing large volume replacement.


the effect of
hyperoncotic albumin is relatively long lasting, with at least
two-thirds of the initial volume expansion effect persisting at
6&#8211;8 h after infusion [19,21].
Hyperoncotic albumin also possesses the capacity to draw
interstitial fluid into the intravascular space, in accord with the
Starling fluid equilibrium equation [23]. Thus, undesirable
edema may be reduced [24].


hyperoncotic albumin more effectively
maintained colloid oncotic pressure than control regimens in
both cardiac [37] and non-cardiac surgery [36]. Compared
with HES, hyperoncotic albumin better preserved renal function
[41] and coagulation [39]. A greater increase in cardiac
output was demonstrated after administration of hyperoncotic
albumin than saline to the same right atrial pressure target
[52]. Hyperoncotic albumin was superior to both HES and
crystalloid in preventing intestinal edema during abdominal
surgery [39].


http://www.biomedcentral.com/content/pdf/cc6812.pdf (Boldt data has been discredited)

 

[BLADEMDA]

Anti-inflammatory activity
Starling forces may be sufficient to explain the effectiveness of
hyperoncotic albumin for small-volume resuscitation and
edema reduction. However, additional mechanisms such as
anti-inflammatory and antioxidant activity may contribute to the
clinical benefits of hyperoncotic albumin. Furthermore, at least
some of these mechanisms are specific to hyperoncotic rather
than 4 to 5% albumin. Thus, in an in vitro study of blood specimens
from 10 healthy adult human volunteers, dilution with
HES 450/0.7 produced a dose-dependent increase in neutrophil
activation to 19-fold the baseline level [80]. The
increase after dilution with various crystalloids was to 13- to
19-fold the baseline level and with 5% albumin twofold. In contrast,
there was no evidence of neutrophil activation by 25%
albumin.
Antioxidant effects
The reduced thiol moiety on cysteine 34 of albumin can play a
direct antioxidant role. In a randomized clinical trial of 20
patients with acute lung injury due to trauma, pneumonia, sepsis
and other insults, repeated administration of 25% albumin
elevated plasma thiol concentration (p = 0.0001) and total
antioxidant capacity (p = 0.033) compared with saline placebo
[81].

 

[BLADEMDA]

Safety
The capacity of hyperoncotic albumin to shift fluid from the
interstitium to the intravascular space may be viewed as a twoedged
sword, depending upon the hydration state of the
patient. In edematous states, such fluid shifts may be
desirable. Conversely, hyperoncotic albumin should probably
be avoided in patients with severe dehydration [3].
High doses of hyperoncotic albumin could potentially increase
pulmonary edema and capillary leak. In one widely cited randomized
trial of Lucas et al. [82], patients receiving very high
hyperoncotic albumin doses (1,142 g) and total fluid volumes
(44.9 l) displayed impairment in pulmonary function.
Commentators have ascribed that result to fluid overload
rather than hyperoncotic albumin per se, however [83,84].

( SUMMARY: TOO MUCH IS BAD!)

 

[BLADEMDA]

So, what is the optimal dosage of Albumin for those big surgical cases? What type of Albumin is best, 5% or 25%? Nobody knows.

I use 1 gram/kg as my limit even though the manufacturer states 2 grams/kg as the limit. For me, this means no more than 2 bottles of Albumin 25% (100 ml bottles) per adult patient.

Albumin 5%

100 ml= 5 grams
250 mls= 12.5 grams
500 mls= 25 grams

Albumin 25%

50 ml= 12.5 grams
100 ml= 25 grams


Never mix sterile water with 25% Albumin and always make sure the patient is hydrated adequately before giving the 25% ( I have an arterial line in place with C.O./C.I. and SVV).

 

[BLADEMDA]

Please understand that there is no solid evidence that Albumin (5% or 25%) alters mortality. I am suggesting that morbidity may be decreased with selective use of Albumin for surgical cases requiring large amounts of fluid resuscitation.

At this time the evidence for using Albumin in the O.R. suite is limited at best. Hence, those who choose to avoid it entirely are being quite reasonable; but, I believe the limited use of Albumin plays a role in reducing morbidity in certain, specific surgical patients.

There is no longer a role or need for any Starch product in the O.R. My advice is get rid of it and replace it with Albumin.

 

[dhb]

I am suggesting that morbidity may be decreased with selective use of Albumin for surgical cases requiring large amounts of fluid resuscitation.

Can you be more specific on which type of case?

 

[Idiopathic]

So, what is the optimal dosage of Albumin for those big surgical cases? What type of Albumin is best, 5% or 25%? Nobody knows.

I use 1 gram/kg as my limit even though the manufacturer states 2 grams/kg as the limit. For me, this means no more than 2 bottles of Albumin 25% (100 ml bottles) per adult patient.

Albumin 5%

100 ml= 5 grams
250 mls= 12.5 grams
500 mls= 25 grams

Albumin 25%

50 ml= 12.5 grams
100 ml= 25 grams


Never mix sterile water with 25% Albumin and always make sure the patient is hydrated adequately before giving the 25% ( I have an arterial line in place with C.O./C.I. and SVV).

I never have any clue as to whether this is your words or someone else's as you dont always attribute your quotes, but explain to me how an arterial line with C.O. Etc will give you any information on "hydration"? Any patient getting 25% would be expected to be "hypovolemic" which would be reflected in your indices mentioned but certainly you can be acutely hypovolemic but also well hydrated. you can also be euvolemic and dehydrated...these would be the people in whom you should avoid hyperoncotic solutions such as 25% albumin

 

[BLADEMDA]

I never have any clue as to whether this is your words or someone else's as you dont always attribute your quotes, but explain to me how an arterial line with C.O. Etc will give you any information on "hydration"? Any patient getting 25% would be expected to be "hypovolemic" which would be reflected in your indices mentioned but certainly you can be acutely hypovolemic but also well hydrated. you can also be euvolemic and dehydrated...these would be the people in whom you should avoid hyperoncotic solutions such as 25% albumin

Slim,

During a big case the SVV can be less than 15 and then quickly go to 22 with blood loss. While giving the LR and blood the SVV goes back to 15 but we know it won't stay there for long while the surgeons continue their bloodletting. Hence, giving some 25 percent albumin would be a solid choice as it will draw some interstitial fluid into the vascular system. This will help with third spacing postop. These large blood loss cases are very dynamic. As i have stated previously the intent of the 25 percent albumin is to both increase intravascular volume And decrease postop third spacing with resulting edema. There are other potential benefits to the 25 percent albumin. Based on best available evidence I'm limiting the amount of 25 percent albumin to no more than 50 grams per patient per day or 1 gram/kg for the smaller patients (e.g. 40 grams for a 40 kg patient).

The 25 percent Albumin is administered once the attending Anesthesiologist is satisfied that adequate volume replacement with plasmalyte, LR, FFP, etc has occurred and the intraop monitors like CI, SVV, SV and urine output are all reasonable. I do not give 25 percent Albumin upfront although there is no data to suggest that such a move would necessarily be deleterious to a healthy patient. I expect a great deal more research will be published in this area over the next few years.

I'm using the Flo Trac system from Edwards LifeSciences. This gives me CO/CI and SVV along with other parameters. An arterial line is required for this system.

http://www.edwards.com/products/mininvasive/Pages/MinInvasiveHome.aspx