Hypotensive effects of stable plasma protein solution (SPPS): a preliminary communication

Human serum albumin induced hypotension in the postoperative phase of cardiac surgery

Hypotension associated with the rapid infusion of human serum albumin products was first recognised in Australasia in the early 1970s. An association with the angiotensin converting enzyme inhibitor class of drugs (ACE-I) followed, leading to a proposed mechanism involving bradykinin generation through pre-kallikrein activator (PKA) presence in the infused fluid. The newer generation albumin products (Albumex) contain very low concentrations of PKA and are generally thought safe to use in most patient populations. Anecdotal reports of paradoxical hypotension with rapid infusion of 4% albumin in our department led to an audit of practice over three months. Four out of 36 patients (11%) who received 4% albumin intravenously experienced paradoxical hypotension. Three of these patients were taking ACE-I preoperatively (P=0.04). There was no observed hypotension associated with intravenous infusion of crystalloid fluid. We believe 4% albumin should be used with caution, particularly in those patients receiving ACE-I preoperatively.

Correlation of hypotensive effect of plasma protein fraction with prekallikrein activator activity: a clinical study in patients having open-heart surgery

We studied the hemodynamic responses to the administration of 20 ml of three protein solutions having different prekallikrein activator (PKA) activities in patients undergoing cardiac operation. PKA levels of the two plasma protein fraction (PPF) solutions studied were 193% and 60%, respectively, while that of the albumin solution was less than or equal to 3%. A significant correlation was found between the PKA activity of the test solutions and the decrease in systemic vascular resistance produced by the solutions during cardiopulmonary bypass and in the postoperative period. Vasodilatation was considerably more marked in the postoperative phase than during cardiopulmonary bypass. Since cardiac output increased simultaneously with the decrease in vascular resistance in the postoperative period, the hypotension observed did not fully reflect the degree of vasodilatation. In some patients, substantial vasodilatation was observed also after the administration of albumin solution with low PKA level. We conclude that although the PPF-induced vasodilatation correlates with the PKA activity of the solution, occasional hypotensive reactions are probably due to mechanisms other than those linked with increased PKA level.

Vasodilator effects of the sodium acetate in pooled protein fraction

Paradoxical hypotension during rapid infusion of plasma protein fraction (PPF) has been attributed to vasodilation by bradykinin in PPF. This study employed a canine, controlled right heart bypass preparation to assess changes in systemic vascular resistance and venous capacitance during infusion of PPF and other possibly vasoactive mediators. Plasma protein fraction caused consistent vasodilation, whereas purified human albumin did not. This vasodilation could be ascribed entirely to acetate, present in PPF as a buffer. Bradykinin in PPF had no effect during venous infusion. Acetate is used widely as a buffer in intravenous and dialysate solutions. Its vasoactive properties must be recognized when such solutions are administered to patients with limited capacity to compensate for sudden vasodilation.

Inhibition of human peptidyl dipeptidase (angiotensin I converting enzyme: kininase II) by human serum albumin and its fragments

Purified peptidyl dipeptidase (angiotensin I converting enzyme or kininase II) from human lung or hog kidney is inhibited by commercially prepared plasma protein preparations, by human serum albumin and by the additive albumin stabilizer, acetyltryptophan. After the initial steps of purification, albumin was detected by immunodiffusion as a component in human lung peptidyl dipeptidase preparation. Fragment C of albumin (sequence 124-298) is a more potent inhibitor than the parent molecule (Ki = 1.7 X 10(-5)M). Reduction and carboxymethylation of five of the six S-S bridges in Fragment C yield the most potent noncompetitive inhibitor (Ki = 3 X 10(-6)M). Reduction of the sixth bridge raises the K1. This indicates that maintenance of the tertiary structure in Fragment C is of importance for the inhibition. Neither albumin nor Fragment C are substrates of the enzyme. Fragment C and its derivative also inhibit the inactivation of bradykinin by the purified human enzyme and by the peptidyl dipeptidase on the surface of intact cultured human endothelial cells.

Reactions to rapid infusion of stable plasma protein solution during large volume plasma exchange

Five per cent heat treated stable plasma protein solution (SPPS) has been rapidly infused into 25 patients, as fluid replacement during large volume plasmapheresis. Reactions were produced in 20 patients. Subjective symptoms of flushing, nasal stuffiness, fullness and throbbing in the head, colicky abdominal pain, metallic taste or apprehension were observed in 16 patients, and 11 patients became hypotensive with an average systolic pressure of 70 mm Hg. These observations support earlier reports of hypotension due to rapid SPPS infusion, and document the occurrence of subjective symptoms which may be the harbingers of a hypotensive reaction. In view of the known presence of a bradykinin-like substance in some heat treated plasma protein solutions, hypotension during SPPS infusion should be interpreted with caution in the light of these findings.