Human albumin solution for resuscitation and volume expansion in critically ill patients

Abstract

Background: Human albumin solutions are used in a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, burns, and hypoproteinaemia. Human albumin solutions are more expensive than other colloids and crystalloids. Objectives: To quantify the effect on mortality of human albumin and plasma protein fraction (PPF) administration in the management of critically ill patients. Search strategy: We searched the Cochrane Injuries Group trials register, CENTRAL (The Cochrane Library issue 2, 2008), MEDLINE, EMBASE, BIDS Index to Scientific and Technical Proceedings, ISI Web of Knowledge: Science Citation Index, Zetoc. Reference lists of trials and review articles were checked, and authors of identified trials were contacted. The search was last updated in June 2008. Selection criteria: Randomised controlled trials comparing albumin/PPF with no albumin/PPF, or with a crystalloid solution, in critically ill patients with hypovolaemia, burns or hypoalbuminaemia. Data collection and analysis: We collected data on the participants, albumin solution used, mortality at the end of follow up, and quality of allocation concealment. Analysis was stratified according to patient type. Main results: We found 37 trials meeting the inclusion criteria and reporting death as an outcome. There were 1686 deaths among 8716 trial participants. For hypovolaemia, the relative risk of death following albumin administration was 1.01 (95% confidence interval 0.93 to 1.11). This estimate was heavily influenced by the results of the SAFE trial which contributed 88.2% of the information (based on the weights in the meta-analysis). For burns, the relative risk was 2.52 (1.22 to 5.22) and for hypoalbuminaemia the relative risk was 1.20 (0.87 to 1.64). There was no substantial heterogeneity between the trials in the various categories (chi-square = 25.25, df = 30, p = 0.71). The pooled relative risk of death with albumin administration was 1.04 (0.96 to 1.13). Authors' conclusions: For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trials.