Colloid solutions for fluid resuscitation

The effect of human albumin administration on postoperative renal function following major surgery: a systematic review and meta-analysis

Optimal fluid management during major surgery is of considerable concern to anesthesiologists. Although crystalloids are the first choice for fluid management, the administration of large volumes of crystalloids is associated with poor postoperative outcomes. Albumin can be used for fluid management and may protect renal function. However, data regarding the effects of albumin administration on kidney function are conflicting. As such, the present study aimed to investigate the effect of albumin administration on renal function in patients undergoing major surgery and compare its effects with those of crystalloid fluid. The Embase, Medline, Web of Science, Cochrane Library, and KoreaMed databases were searched for relevant studies. The primary endpoint of the meta-analysis was the incidence of postoperative kidney injury, including acute kidney injury and renal replacement therapy. Twelve studies comprising 2311 patients were included; the primary endpoint was analyzed in four studies comprising 1749 patients. Perioperative albumin levels in patients undergoing major surgery did not significantly influence kidney dysfunction (p = 0.98). Postoperative fluid balance was less positive in patients who underwent major surgery and received albumin than in those who received crystalloids. Owing to the limitations of this meta-analysis, it remains unclear whether albumin administration during major surgery is better than crystalloid fluid for improving postoperative renal function.

Recipient pre-existing chronic hypotension is associated with delayed graft function and inferior graft survival in kidney transplantation from elderly donors

BACKGROUND

Pre-existing chronic hypotension affects a percentage of kidney transplanted patients (KTs). Although a relationship with delayed graft function (DGF) has been hypothesized, available data are still scarce and inconclusive.

METHODS

A monocentric retrospective observational study was performed on 1127 consecutive KTs from brain death donors over 11 years (2003-2013), classified according to their pre-transplant Mean Blood Pressure (MBP) as hypotensive (MBP < 80 mmHg) or normal-hypertensive (MBP ≥ 80 mmHg, with or without effective antihypertensive therapy).

RESULTS

Univariate analysis showed that a pre-existing hypotension is associated to DGF occurrence (p<0.01; OR for KTs with MBP < 80 mmHg, 4.5; 95% confidence interval [CI], 2.7 to 7.5). Chronic hypotension remained a major predictive factor for DGF development in the logistic regression model adjusted for all DGF determinants. Adjunctive evaluations on paired grafts performed in two different recipients (one hypotensive and the other one normal-hypertensive) confirmed this assumption. Although graft survival was only associated with DGF but not with chronic hypotension in the overall population, stratification according to donor age revealed that death-censored graft survival was significantly lower in hypotensive patients who received a KT from >50 years old donor.

CONCLUSIONS

Our findings suggest that pre-existing recipient hypotension, and the subsequent hypotension-related DGF, could be considered a significant detrimental factor, especially when elderly donors are involved in the transplant procedure.

A scoping review of retracted publications in anesthesiology

Context:

Fraudulent publication is a scourge of scientific research.

Objectives:

This scoping review was aimed at characterizing retracted publications for fraud or plagiarism in the field of anesthesia. Does the reputation of the journal (Quartile and Impact Factor, IF) protect the reader from the risk of having the manuscript he read withdrawn for fraud/plagiarism?

Methods/Design:

This scoping review was planned following the Joanna Briggs Institute recommendations. Data sources: PubMed and the Retraction Watch Database (http://retractiondatabase.org/RetractionSearch.aspx?). Study selection: All types of publications retracted. Data extraction: Year, first author nationality, journal name, journal category, IF, Quartile, H index. Data analysis: The association with Quartile and IF was investigated.

Results:

No significant association between retraction of papers published in no-Quartile journals and retractions published in journals placed in the highest quartile.

Conclusions:

The quality of the surveillance in paper submission is not higher in journals of the first Quartile than in journals not placed in other Quartiles. (The protocol was prospectively registered in the Open Science Framework https://doi.org/10.17605/OSF.IO/TGKNE)

Early combination of albumin with crystalloids administration might be beneficial for the survival of septic patients: a retrospective analysis from MIMIC-IV database

Background

Fluid therapy is a cornerstone in the treatment of sepsis. Recently, the guidelines have recommended the combined administration that using crystalloids plus albumin for septic patients, but the optimal timing for albumin combined is still unclear. The objective of this study was to investigate the association of timing of albumin combined with 28-day mortality in patients with sepsis.

Methods

We involved septic patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database, and these patients were categorized into crystalloids group (crystalloids alone) and early combination group (crystalloids combined albumin at 0–24 h). The primary outcome was 28-day mortality. We used propensity score matching (PSM) to adjust confounding and restricted mean survival time (RMST) analysis was conducted to quantify the beneficial effect on survival due to the combination group.

Results

We categorized 6597 and 920 patients in the “crystalloids alone” and “early combination”, respectively. After PSM, compared to the crystalloids group, the combination group was associated with the increased survival among 28-day (increased survival: 3.39 days, 95% CI 2.53–4.25; P < 0.001) after ICU admission. Patients who received albumin combination at the first 24-h was associated with prolonged LOS in ICU (10.72 days vs. 8.24 days; P < 0.001) but lower risk of 28-day mortality (12.5% vs 16.4%, P = 0.003) than those received crystalloids alone.

Conclusion

In septic patients, receiving albumin combined within the first 24-h after crystalloids administration was associated with an increment of survival in 28 days.

Effects of hydroxyethyl starch and gelatin on the risk of acute kidney injury following orthotopic liver transplantation: A multicenter retrospective comparative clinical study

Objectives

This multicenter retrospective study aimed to compare the effects of HES and gelatin (GEL) on the risk of post-OLT AKI.

Method

A total of 1,672 patients undergoing OLT were enrolled from major transplant centers in China between 2005 and 2013. These patients were divided into three groups: GEL, hydroxyethyl starch (HES), and GEL + HES group.

Results

There was no significant difference in the incidence of post-OLT AKI among the GEL, HES, and GEL + HES groups. The GEL + HES group had a lower incidence of stage II post-OLT AKI than the other two groups. Compared with patients receiving GEL, patients receiving HES did not harbor an increased risk of AKI. Our results showed that MELD score (adjusted odds ratio [OR], 1.579; 95% confidence interval [CI], 1.123–2.219; P = 0.009) and preoperative anemia (adjusted OR, 1.533; 95% CI, 1.212–1.939; P < 0.001) were independent risk factors for post-OLT AKI, and normal preoperative Scr level (vs abnormal; adjusted OR, 0.402; 95% CI, 0.222–0.729; P = 0.003) was independent protective factors for post-OLT AKI.

Conclusion

This large-scale multicenter retrospective study found that the intraoperative use of HES did not increase the overall incidence of post-OLT AKI in patients when compared with GEL, and whether to increase the risk of post-OLT AKI needs to be further explored.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

Acute kidney injury in postoperative shock: is hyperoncotic albumin administration an unrecognized resuscitation risk factor?

BACKGROUND

The use of hyperoncotic albumin (HA) for shock resuscitation is controversial given concerns about its cost, effectiveness, and potential for nephrotoxicity. We evaluated the association between early exposure to hyperoncotic albumin (within the first 48 h of onset of shock) and acute organ dysfunction in post-surgical patients with shock.

METHODS

This retrospective, cohort study included 11,512 perioperative patients with shock from 2009 to 2012. Shock was defined as requirement for vasopressors to maintain adequate mean arterial pressure and/or elevated lactate (> 2.2 mmol/L). Subsets of 3600 were selected after propensity score and exact matching on demographics, comorbidities, and treatment variables (> 30). There was a preponderance of cardiac surgery patients. Proportional odds logistic regression, multivariable logistic regression or Cox proportional hazard regression models measured association between hyperoncotic albumin and acute kidney injury (AKI), hepatic injury, ICU days, and mortality.

RESULTS

Hyperoncotic albumin-exposed patients showed greater risk of acute kidney injury compared to controls (OR 1.10, 95% CI 1.04, 1.17. P = 0.002), after adjusting for imbalanced co-variables. Within matched patients, 20.3%, 2.9%, and 4.4% of HA patients experienced KDIGO stages 1-3 AKI, versus 19.6%, 2.5%, and 3.0% of controls. There was no difference in hepatic injury (OR 1.16; 98.3% CI 0.85, 1.58); ICU days, (HR 1.05; 98.3% CI 1.00, 1.11); or mortality, (OR 0.88; 98.3% CI 0.64, 1.20).

CONCLUSIONS

Early exposure to hyperoncotic albumin in postoperative shock appeared to be associated with acute kidney injury. There did not appear to be any association with hepatic injury, mortality, or ICU days. The clinical and economic implications of this finding warrant further investigation.

Comparison of dextran and albumin on blood coagulation in patients undergoing major gynaecological surgery

Background

Hydroxyethyl starches have been withdrawn from the European market. In Sweden, dextran was the main colloid until 2000, when starches overtook the market. After the recent 6S-trial, it was suggested that dextran could be reinstituted, but concerns for greater coagulopathy, bleeding and anaphylaxis still remain. An experimental study from our department indicated that isovolemic substitution of dextran-70 did not derange the von Willebrand function more than albumin 5%, considering the fact that dextran is hyperoncotic in comparison to albumin 5% and, therefore, induces a greater plasma volume expansion and thereby a greater dilutional coagulopathy.

Methods

Eighteen patients undergoing major gynaecological surgery were assigned to receive either 5% albumin or 6% dextran-70 with 9 patients in each group. Standard coagulation tests, including prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and platelet count, viscoelastic coagulation test thromboelastometry (ROTEM) and the Multiplate platelet aggregation test were used to test for coagulation defects at different time points perioperatively. Blood loss, blood loss replacement data and haemodynamic parameters were retrieved from anaesthetic and postoperative charts. A local departmental fluid and transfusion/infusion protocol assured haemoglobin > 90 g/l and mean arterial pressure > 65 mmHg with Ringer’s acetate in addition to the colloid use.

Results

There were no differences in demographic data between the groups. The tissue factor-activated (EXTEM) clot-structure parameter ROTEM A10 was decreased significantly in the dextran group as compared to the albumin group after the infusion of 500 ml of either colloid solution. The PT and aPTT were significantly prolonged, and the platelet count decreased postoperatively in the dextran group, whereas albumin only deranged fibrinogen levels as compared to preoperative levels. There were no differences in Multiplate platelet aggregometry, amount of haemorrhage or transfusion of blood components between the groups.

Conclusions

Standard plasma-based coagulation tests, platelet count and whole blood viscoelastic clot structure are affected by 6% dextran-70 to a greater extent than by 5% albumin, but platelet aggregation is not. Future studies should use more advanced haemodynamic monitoring to assess isovolemic plasma volume expansion with dextran and whether this affects haemostasis to a lesser degree.

Predictors of major complications after elective abdominal surgery in cancer patients

Background

Patients undergoing abdominal surgery for solid tumours frequently develop major postoperative complications, which negatively affect quality of life, costs of care and survival. Few studies have identified the determinants of perioperative complications in this group.

Methods

We performed a prospective observational study including all patients (age > 18) undergoing abdominal surgery for cancer at a single institution between June 2011 and August 2013. Patients undergoing emergency surgery, palliative procedures, or participating in other studies were excluded. Primary outcome was a composite of 30-day all-cause mortality and infectious, cardiovascular, respiratory, neurologic, renal and surgical complications. Univariate and multiple logistic regression analyses were performed to identify predictive factors for major perioperative adverse events.

Results

Of a total 308 included patients, 106 (34.4%) developed a major complication during the 30-day follow-up period. Independent predictors of postoperative major complications were: age (odds ratio [OR] 1.03 [95% CI 1.01–1.06], p = 0.012 per year), ASA (American Society of Anesthesiologists) physical status greater than or equal to 3 (OR 2.61 [95% CI 1.33–5.17], p = 0.003), a preoperative haemoglobin level lower than 12 g/dL (OR 2.13 [95% CI 1.21–4.07], p = 0.014), intraoperative use of colloids (OR 1.89, [95% CI 1.03–4.07], p = 0.047), total amount of intravenous fluids (OR 1.22 [95% CI 0.98–1.59], p = 0.106 per litre), intraoperative blood losses greater than 500 mL (2.07 [95% CI 1.00–4.31], p = 0.043), and hypotension needing vasopressor support (OR 4.68 [95% CI 1.55–27.72], p = 0.004). The model had good discrimination with the area under the ROC curve being 0.80 (95% CI 0.75–0.84, p < 0.001).

Conclusions

Our findings suggest that a perioperative strategy aimed at reducing perioperative complications in cancer surgery should include treatment of preoperative anaemia and an optimal fluid strategy, avoiding fluid overload and intraoperative use of colloids.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0516-6) contains supplementary material, which is available to authorized users.

Effectiveness and Safety of Polygeline in Patients with Hypovolemia due to Trauma

Background:

This retrospective study examined the effectiveness and safety of polygeline in adult patients with hypovolemia due to traumatic injury.

Materials and Methods:

Polygeline was administered after evaluating the amount of blood loss and estimating hematological and biochemical parameters. Changes in vital signs, serum electrolytes, arterial pH, and serum lactate were evaluated. The safety was evaluated by recording the adverse events if any.

Results:

Sixty patients with the mean age 37.5 ± 11.26 years were included in the study. All patients had blood loss < 20%. The mean total polygeline administered was 1025.0 ± 464.18 ml. Blood transfusion was required in 3.33% of patients. Diastolic, systolic, and mean arterial blood pressure and pulse rate significantly increased after 1 h of polygeline administration (P < 0.0001). There was a trend toward increase in urine output (P = 0.0715) after 1 h. The improvement in vital parameters was consistent at 6, 14, and 18 h after administration of polygeline. Arterial pH significantly increased from 7.2 ± 0.12 to 7.3 ± 0.11 after 1 h of administration (P < 0.0001) and was consistent till 24 h (P = 0.035). Blood lactate decreased after 1 h (P < 0.0001). Changes in laboratory parameters were not clinically significant. After mean duration hospital stay of 10.5 ± 4.63 days all patients were discharged without any clinically significant abnormality or adverse event.

Conclusion:

Polygeline improved hemodynamic stability in patients with hypovolemia due to traumatic injury. The improvement was seen within 1 h (golden hour) of polygeline administration and maintained consistently. Polygeline can be safely administered to patients with traumatic injury to improve hemodynamic parameters and achieve stability.

Hydroxyethyl starch resuscitation downregulate pro-inflammatory cytokines in the early phase of severe acute pancreatitis: A retrospective study

In the present study, we investigated the effects of hydroxyethyl starch (HES) 130/0.4 on serum pro-inflammatory variables, immunologic variables, fluid balance (FB)-negative(-) rate and renal function in severe acute pancreatitis (SAP) patients. From October, 2007 to November, 2008, a total of 120 SAP patients were enrolled in this retrospective study. Fifty-nine patients in the HES group received 6% HES 130/0.4 combined with crystalloid solution for fluid resuscitation (HES group). In the control group, 61 patients received only crystalloid solution after admission. Interleukin (IL)-1, IL-6, IL-8 and tumor necrosis factor (TNF)-α levels in serum were measured on days 1, 2, 4 and 8. The peripheral blood CD4+CD8+ T lymphocyte rates, serum BUN and Cr values were also measured on days 1, 4 and 8. Patients with FB(-) rates were recorded from day 1 to 8. Interaction term analysis (hospital stay and fluid resuscitation methods) based on mixed-effects regression model revealed significantly lower levels of IL-1 and TNF-α in the HES group compared with the control group. The difference in curve's risk ratio was not significant for IL-6, CD4+CD8+ T lymphocyte rate, BUN and Cr values (P>0.05). In the HES group, we detected a significantly higher rate of patients with FB(-) from day 4 to 8 (P<0.05). Thus, HES 130/0.4 resuscitation could decrease the IL-1 and IL-8 levels, shorten the duration of positive FB, and preserve the patient's immune status as well as renal function during the early phase of SAP.

Effect of perioperative crystalloid or colloid fluid therapy on hemorrhage, coagulation competence, and outcome: A systematic review and stratified meta-analysis

BACKGROUND

A meta-analysis concerning perioperative coagulation competence, hemorrhage, and outcome was conducted including the use of hydroxyethyl starches (HESs), dextran, or albumin versus administration of a crystalloid as control to assess the efficacy and safety of colloids and crystalloids for fluid administration during major elective surgery. Surgery was restricted to cardiovascular and noncardiovascular surgery, and HESs were stratified to HES 130/0.4 and HES 200/0.5.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, ISI Web of Science, EMBASE, conference proceedings, reference lists, and databases of ongoing trials.

RESULTS

Thirty one primary clinical randomized controlled trials included 2287 patients undergoing major surgery from January 2000 to August 2015. The perioperative changes in coagulation competence were measured by thromboelastography (TEG) maximum amplitude (MA) in 9 studies administering crystalloids versus HES and in 4 studies administering albumin versus HES. All studies but 1 disclosed increased reduction in TEG-MA following HES administration (P = 0.0001 and 0.0002). The total loss of blood was reported in 17 studies in which crystalloids were compared to HES and 12 studies reported increased blood loss after administration of HES (P < 0.003). When administering albumin versus HES, 6 studies reported reduced hemorrhage associated with albumin administration (P = 0.005). Reoperation was not significantly reduced by the use of crystalloids, but may be more frequent after HESs compared to albumin (P < 0.03). In this analysis, more patients admitted to administration of HESs were exposed to decrease coagulation competence, compared to perioperative crystalloids and albumin administration.

CONCLUSION

This stratified meta-analysis showed that increased blood loss was found in noncardiovascular surgery among patients receiving HES compared with crystalloids, followed by a marked reduction in TEG-MA, and infusion of 3rd-generation HES products did not influence the results significantly.

Albumin Kinetics in Patients Undergoing Major Abdominal Surgery

Background

The drop in plasma albumin concentration following surgical trauma is well known, but the temporal pattern of the detailed mechanisms behind are less well described. The aim of this explorative study was to assess changes in albumin synthesis and transcapillary escape rate (TER) following major surgical trauma, at the time of peak elevations in two well-recognized markers of inflammation.

Methods

This was a clinical trial of radiolabeled human serum albumin for the study of TER and plasma volume. Ten patients were studied immediately preoperatively and on the 2nd postoperative day after major pancreatic surgery. Albumin synthesis rate was measured by the flooding dose technique employing incorporation of isotopically labelled phenylalanine.

Results

Fractional synthesis rate of albumin increased from 11.7 (95% CI: 8.9, 14.5) to 15.0 (11.7, 18.4) %/day (p = 0.027), whereas the corresponding absolute synthesis rate was unchanged, 175 (138, 212) versus 150 (107, 192) mg/kg/day (p = 0.21). TER was unchanged, 4.9 (3.1, 6.8) %/hour versus 5.5 (3.9, 7.2) (p = 0.63). Plasma volume was unchanged but plasma albumin decreased from 33.5 (30.9, 36.2) to 22.1 (19.8, 24.3) g/L. (p<0.001).

Conclusion

Two days after major abdominal surgery, at the time-point when two biomarkers of generalised inflammation were at their peak and the plasma albumin concentration had decreased by 33%, we were unable to show any difference in the absolute synthesis rate of albumin, TER and plasma volume as compared with values obtained immediately pre-operatively. This suggests that capillary leakage, if elevated postoperatively, had ceased at that time-point. The temporal relations between albumin kinetics, capillary leakage and generalised inflammation need to be further explored.

Trial Registration

clinicaltrialsregister.eu: EudraCT 2010-08529-21 ClinicalTrials.gov NCT01194492

Efficacy of limited fluid resuscitation in patients with hemorrhagic shock: a meta-analysis

BACKGROUNDS

The objective of this meta-analysis was to evaluate the efficacy of limited fluid resuscitation during active hemorrhage compared with regular fluid resuscitation and provide strong evidences for the improvement of fluid resuscitation strategies in uncontrolled hemorrhagic shock.

METHODS

Electronic searches were performed using PubMed, Medline, Embase and CNKI in accordance with pre-set guidelines. Clinical trials and observation studies were included or excluded according to the criteria. The endpoints examined were mortality, hemoglobin (Hb), platelets (PLT), hematocrit (Hct), prothrombin Time (PT), activated partial thromboplastin time (APTT), base excess (BE), blood lactic acid (BLA) and the main complications, such as multiple organ dysfunction syndrome (MODS) and acute Respiratory Distress Syndrome (ARDS). Risk ratios (RR), mean differences (MDs) and 95% confidence intervals (95% Cl) were calculated using fixed/random effect model.

RESULTS

The search indentified 11 studies including 1482 subjects. 725 hemorrhagic patients were treated with limited fluid resuscitation while 757 patients undertook regular fluid resuscitation during active hemorrhage. Limited fluid resuscitation had its advantage to reduce the mortality in hemorrhagic shock (RR = 0.67; 95% CI = 0.56-0.81; P < 0.0001) and easily controlled the blood routine index close to normal compared with regular fluid resuscitation (Hb: MD = 13.04; 95% CI = 2.69-23.38; P = 0.01. PLT: MD = 23.16; 95% CI = 6.41-39.91; P = 0.007. Hct: MD = 0.02; 95% CI = 0.02-0.03; P < 0.00001). LFR also had shorter PT and APTT compared with RFR (PT: MD = -2.81; 95% CI = -3.44--2.17; P < 0.00001 and APTT: MD = -5.14; 95% CI = -6.16--4.12; P < 0.00001). As for blood gas analysis, LFR reduced the decrease of BE (MD = 2.48; 95% CI = 1.11-3.85; P = 0.0004) and increase of BLA (MD = -0.65; 95% CI = -0.85--0.44; P < 0.00001). Besides, LFR may also reduce the occurrence of postoperative complications (MODS: RR= 0.37; 95% CI = 0.21-0.66; P = 0.0008. ARDS: RR = 0.35; 95% CI = 0.21-0.60; P < 0.0001).

CONCLUSION

The results provide convincing evidence that support the continued investigation and use of limited fluid resuscitation during active hemorrhage in the trauma setting.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

OBJECTIVE

To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.

DESIGN

Retrospective cohort study of population based data between 2006 and 2013.

SETTING

Data from 510 different hospitals across the United States participating in the Premier Perspective database.

PARTICIPANTS

1,051,441 patients undergoing elective total hip and knee arthroplasties.

EXPOSURES

Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither.

MAIN OUTCOME MEASURES

Acute renal failure and thromboembolic, cardiac, and pulmonary complications.

RESULTS

Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased.

CONCLUSIONS

Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.

Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality

OBJECTIVE

To assess the efficacy and safety of pooled human albumin solutions as part of fluid volume expansion and resuscitation (with or without improvement of baseline hypoalbuminaemia) in critically unwell adults with sepsis of any severity.

DESIGN

Systematic review and meta-analysis of randomised clinical trials, with trial sequential analysis, subgroup, and meta-regression analyses.

DATA SOURCES

PubMed, PubMed Central, Web of Science (includes Medline, Conference Proceedings Citation Index, Data Citation Index, Chinese Science Citation Database, CAB abstracts, Derwent Innovations Index), OvidSP (includes Embase, Ovid Medline, HMIC, PsycINFO, Maternity and Infant Care, Transport Database), Cochrane Library, clinicaltrials.gov, controlled-trials.com, online material, relevant conference proceedings, hand searching of reference lists, and contact with authors as necessary.

ELIGIBILITY CRITERIA

Prospective randomised clinical trials of adults with sepsis of any severity (with or without baseline hypoalbuminaemia) in critical or intensive care who received pooled human albumin solutions as part of fluid volume expansion and resuscitation (with or without improvement of hypoalbuminaemia) compared with those who received control fluids (crystalloid or colloid), were included if all-cause mortality outcome data were available. No restriction of language, date, publication status, or primary study endpoint was applied.

DATA EXTRACTION

Two reviewers independently assessed articles for inclusion, extracted data to assess risk of bias, trial methods, patients, interventions, comparisons, and outcome. The relative risk of all-cause mortality was calculated using a random effects model accounting for clinical heterogeneity.

PRIMARY OUTCOME MEASURE

All-cause mortality at final follow-up.

RESULTS

Eighteen articles reporting on 16 primary clinical trials that included 4190 adults in critical or intensive care with sepsis, severe sepsis, or septic shock. A median of 70.0 g daily of pooled human albumin was received over a median of 3 days by adults with a median age of 60.8 years as part of fluid volume expansion and resuscitation, with or without correction of hypoalbuminaemia. The relative risk of death was similar between albumin groups (that received a median of 175 g in total) and control fluid groups (relative risk 0.94; 95% confidence interval 0.87 to 1.01; P=0.11; I(2)=0%). Trial sequential analysis corrected the 95% confidence interval for random error (0.85 to 1.02; D(2)=0%). Eighty eight per cent of the required information size (meta-analysis sample size) of 4894 patients was achieved, and the cumulative effect size measure (z score) entered the futility area, supporting the notion of no relative benefit of albumin (GRADE quality of evidence was moderate). Evidence of no difference was also found when albumin was compared with crystalloid fluid (relative risk 0.93; 0.86 to 1.01; P=0.07; I(2)=0%) in 3878 patents (GRADE quality of evidence was high; 79.9% of required information size) or colloid fluids in 299 patients (relative risk 1.04; 0.79 to 1.38; P=0.76; I(2)=0%) (GRADE quality of evidence was very low; 5.8% of required information size). When studies at high risk of bias were excluded in a predefined subgroup analysis, the finding of no mortality benefit remained, and the cumulative z score was just outside the boundary of futility. Overall, the meta-analysis was robust to sensitivity, subgroup, meta-regression, and trial sequential analyses.

CONCLUSIONS

In this analysis, human albumin solutions as part of fluid volume expansion and resuscitation for critically unwell adults with sepsis of any severity (with or without baseline hypoalbuminaemia) were not robustly effective at reducing all-cause mortality. Albumin seems to be safe in this setting, as a signal towards harm was not detected, but this analysis does not support a recommendation for use.

Role of colloids in traumatic brain injury: Use or not to be used?

Trauma is a leading cause of death worldwide and traumatic brain injury is one of the commonest injuries associated with it. The need for urgent resuscitation is warranted for prevention of secondary insult to brain. However, the choice of fluid in such cases is still a matter of conflict. The literature does not provide enough data pertaining to role of colloids in head injury patients. In this article, we have tried to explore the present role of colloid resuscitation in patient with head injury.

Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy

PURPOSE

To determine whether fluid resuscitation of acutely ill adults with 6 % hydroxyethyl starch (6 % HES 130) with a molecular weight of 130 kD and a molar substitution ratio of approximately 0.4 (6 % HES 130) compared with other resuscitation fluids results in a difference in the relative risk of death or treatment with renal replacement therapy (RRT).

METHODS

Systematic review and meta-analysis of randomized controlled trials comparing intravascular fluids for resuscitation of hospitalised adults that reported mortality or treatment with RRT. The risk of bias was assessed independently by two reviewers and meta-analysis was performed using random effects.

RESULTS

Thirty-five trials enrolling 10,391 participants were included. The three largest trials had the lowest risk of bias, were published (or completed) in 2012, and together enrolled 77 % of all participants. Death occurred in 928 of 4,691 patients (19.8 %) in the 6 % HES 130 group versus 871 of 4,720 (18.5 %) in the control fluid groups relative risk (RR) in the 6 % HES 130 group 1.08, 95 % confidence interval (CI) 1.00 to 1.17, I (2) = 0 %). Treatment with RRT occurred in 378 of 4,236 patients (8.9 %) in the 6 % HES 130 group versus 306 of 4,260 (7.2 %) in the control fluid group (RR in the 6 % HES 130 group 1.25, 95 % CI 1.08 to 1.44, I (2) = 0 %).

CONCLUSIONS

The quality and quantity of data evaluating 6 % hydroxyethyl starch (130/0.4 and 130/0.42) as a resuscitation fluid has increased in the last 12 months. Patients randomly assigned to resuscitation with 6 %HES 130 are at significantly increased risk of being treated with RRT.