September 2018 Journal Club

Hi Everyone

Welcome to September’s Journal club, this month we’re going to be looking at that old chestnut Albumin…..

Have a read of the paper here https://www.nejm.org/doi/full/10.1056/NEJMoa1305727

Cheers

Rob

“Hi All

Interesting that the post hoc analysis of patients with septic shock at time of enrolment, did find a statistically significant difference in 90 day mortality (see attached snapshot of the appendix).  Presumably that would make up the vast majority of septic patients admitted to ICU in the UK??”

“I’ve always been a keen user of albumin for specific patients groups so its interesting to review some of the evidence for its use in critical care. I agree that the management of critical care patients is made up of a number of variable pieces dependant on the individual patient and so its often hard to believe that one single change can make a difference to overall outcome. So what does this paper add…..

Well firstly, things have changed a bit since this paper was published i.e. sepsis definitions, goal directed therapy, use of dopamine (25% in this study) and dobutamine (15% in this study), use of steroids (<25% in this study), use of HES……so I’m not sure how relevant it is now.

Secondly, I’m not sure how useful serum albumin levels are as an endpoint for IV albumin administration.

Finally, patients in this study were recruited at any point during their ICU stay if they fulfilled the inclusion criteria. I’m just not sure that the physiology of a first day ICU patient is the same as a day 15 ICU patient in terms of fluid management.

So I think the main thing I would take from this paper is that if nothing else Albumin doesn’t seem to cause any harm and may possibly result in better haemodynamic parameters and lower fluid administration in the first 2 days (albeit marginal).

Would I still go on prescribing Albumin……probably…..but I would continue being selective in who to use it for.”

“Hi Everyone
Thanks again to everyone who has contributed so far it’s great to hear your thoughts!
I think albumin is the ultimate Hokey-Cokey fluid as sometimes it’s in and sometimes it’s out of fashion. That’s partly due to the fact that over the years some studies have suggested harm and some have suggested benefit. There’s a nice summary of the albumin story here https://lifeinthefastlane.com/ccc/albumin/.

This month’s paper (ALBIOS) used 20% albumin in addition to crystalloids to maintain a target serum albumin. As x pointed out they enrolled patients at any point in their ICU stay thus creating a very heterogeneous group about which it’s difficult to draw many black and white conclusions. Hence the lack of any statistically significant difference in the primary outcomes.

However as x said the subgroup analysis did show improved outcomes in patients with septic shock and this corroborates with subgroup analysis from the SAFE study too. And we can also say that this study adds to the weight of evidence now telling us that albumin is safe, which is good to know!

So how should we use it?
Well if it doesn’t do any harm (and may very well do good) I think it should be considered as the fluid of choice for the resuscitation of patients with septic shock as part of a “fluid conservative” strategy. With the usual caveat that if the patient isn’t fluid responsive don’t give anything but instead crack open the vasopressors….
I’d continue to avoid it in brain injury patients.
I wouldn’t use it to correct hypoalbuminaemia (that’s what nutrition is for…).
I’d continue to use it in liver patients with SBP.

Hope that makes sense! Any questions please feel free to share with the group.
Cheers
Rob”

 

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