Critical illness: albumin increase death.

Clinical bottom line (level 1a)

  1. Critically ill patients with hypovolaemia, burns or hypoalbuminaemia who are given human albumin, are more likely to die than those not given albumin (NNH = 15 at unknown) .
The Albumin Reviewers (Alderson P, Bunn F, Lefebvre C, Li Wan Po A, Roberts I, Schierout G) : The Cochrane Library, Issue 3, 1998. Oxford: Update Software 1998; issue3: -
Expires July 2003

The study

Systematic review of randomised controlled trials of
  • Patients: critically ill patients with hypovolaemia, burns or hypoalbuminaemia
  • Intervention: human albumin and plasma protein fraction (PPF) compared with no albumin/PPF
  • Outcome: mortality


    • Articles found in all using Cochrane Controlled Trials Register, MEDLINE, EMBASE, BIDS Index of Scientific and Technical Proceedings, up to 1998 (search terms: detailed in text ) and hand searching 29 international journals and the proceedings of several international meetings on fluid therapy, by checking the reference lists of trials and review articles, and by contacting the authors of all identified trials asking about any other trials that may have been conducted, whether published or unpublished.

    Selection criteria: as above
    Appraisal criteria: selected by two independent blinded reviewers using set criteria (detailed in text)
    Articles excluded if: patients receiving preoperative volume loading or haemodilution, or albumin administration during paracentesis

    30 studies involving 1419 patients were included- 16 in post-operative patients, 5 in burns or trauma patients, 6 in patients with low albumin, 4 in neonates, 1 in patients with a vascular leak.
    There was no significant heterogeneity.

    The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NNH
    (95% CI)
    mortality unknown 58/715
    (8.1%)    		 1.95
    (1.37 to 2.78)     		15
    (9 to 37)

    Comments

    1. The wide range of patient populations, co interventions over the long timescale of the trials and difficulties with quality of trials included make this subject ripe for a high quality RCT.
    2. Albumin is believed to have anticoagulant properties, inhibiting platelet aggregation and enhancing the inhibition of factor Xa by antithrombin III (Soni, 1995). Such anticoagulant activity might be detrimental in critically ill patients, particularly those with haemorrhagic hypovolaemia. Furthermore, albumin has been shown to distribute across the capillary membrane, a process that is accelerated in critically ill patients. It has been suggested that increased leakage of albumin into the extravascular spaces might reduce the oncotic pressure difference across the capillary wall, making oedema more likely.

    Citation

    1. The Albumin Reviewers (Alderson P, Bunn F, Lefebvre C, Li Wan Po A, Roberts I, Schierout G) , : Human albumin solution for resuscitation and volume expansion in critically ill patients. The Cochrane Library, Issue 3, 1998. Oxford: Update Software 1998; issue3: -
    Search Terms: albumin in Cochrane
    Contributor: Chris Ball and Clare Wotton, April 2000
    Reviewer: Dirk Stengel

    Clinical Question.
    Patient critically ill
    Intervention or Exposure albumin
    Comparison no albumin
    Outcome mortality