Small volume resuscitation with 20% albumin in intensive care: physiological effects: The SWIPE randomised clinical trial

Mårtensson J, Bihari S, Bannard-Smith J, Glassford NJ, Lloyd-Donald P, Cioccari L, et al. Intensive Care Med. 2018;44:1797–806.

Patients admitted to intensive care units (ICUs) are often haemodynamically unstable, particularly those with sepsis or septic shock. One treatment strategy to rapidly regain haemodynamic stability may be through small volume resuscitation with higher concentrations of albumin.

In the UK and Australia, albumin concentrations used are either similar to plasma (5% and 4%, respectively) or a more concentrated solution of 20–25%. Small volume resuscitation could result in less fluid accumulation in the tissues, but this strategy remains unproven and has met some concerns, particularly over the safety and efficacy of 20% albumin. (Payen et al., 2008; Bellomo et al., 2012; Acheampong & Vincent, 2015; Garzotto et al., 2016; Silversides et al., 2017). One concern is the induction of a hyperoncotic state as a result of rapid administration. This increase in oncotic pressure may decrease the glomerular filtration rate (GFR), resulting in insufficient intravascular volume expansion (Moran & Kapsner, 1987; Honore et al., 2008; Schortgen et al., 2008).

The Small volume resuscitation With albumin in Intensive Care: Physiological Effects (SWIPE) trial set out to systematically investigate the effects of 20% albumin resuscitation on volume requirements, fluid balance, physiological and biochemical responses in an international, multi-centre, open-label, randomised control setting (figure 1) (Mårtensson et al., 2018).

Summary of the SWIPE study (Mårtensson et al., 2018).

Figure 1. Summary of the SWIPE study (Mårtensson et al., 2018).


Key findings from the SWIPE study

The SWIPE trial has provided interesting insights into small volume resuscitation and the efficacy of 20% albumin. In this study 20% albumin appeared to result in the use of a lower volume of resuscitation fluids in comparison to 4–5% albumin. In fact, the volume of resuscitation fluids was lower than seen in previous colloid studies, although comparative studies have included a larger number of patients with sepsis which may explain the difference (Finfer et al., 2004; Myburgh et al., 2012; Caironi et al., 2014).

The benefits of 20% albumin were also reflected in the lower volume of study fluid, faster haemodynamic stabilisation while no significant differences in key safety outcomes were observed. These safety outcomes have led Mårtensson et al. to suggest that concerns regarding a negative renal impact may even be unwarranted. However, there were some limitations to the SWIPE trial. These included, stopping the trial early, its open-label nature, a number of protocol violations, a lack of generalisability, and a limited number of patients with sepsis. 

Could small volume resuscitation become a part of routine clinical practice? While the SWIPE trial has shown promising results, future studies are needed with larger sample sizes, fluid data over 48 hours, and comparisons to crystalloid solutions to fully understand the effects of small volume resuscitation.

Learn more about the SWIPE trial

Explore the Fluid Management Knowledge Centre to discover more about the role of fluid therapy in cardiac surgery, critically ill patients, liver cirrhosis, and more.

Catch-up on the debate surrounding hydroxyethyl starch use as we take you on an interactive journey through its changing fortunes. Do you think current restrictions will be enough to change clinical practice?

References

Acheampong A, Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis. Crit Care. 2015;19:251.

Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lee J, et al. An observational study fluid balance and patient outcomes in the randomized evaluation of normal vs. augmented level of replacement therapy trial. Crit Care Med. 2012;40:1753–60.

Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370:1412–21.

Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247–56.

Garzotto F, Ostermann M, Martin-Langerwerf D, Sanchez-Sanchez M, Teng J, Robert R, et al. The dose response multicentre investigation on fluid assessment (DoReMIFA) in critically ill patients. Crit Care. 2016;20:196.

Honore PM, Joannes-Boyau O, Boer W. Hyperoncotic colloids in shock and risk of renal injury: enough evidence for a banning order? Intensive Care Med. 2008;34:2127–9.

Mårtensson J, Bihari S, Bannard-Smith J, Glassford NJ, Lloyd-Donald P, Cioccari L, et al. Small volume resuscitation with 20% albumin in intensive care: physiological effects: The SWIPE randomised clinical trial. Intensive Care Med. 2018;44:1797–806.

Moran M, Kapsner C. Acute renal failure associated with elevated plasma oncotic pressure. N Engl J Med. 1987;317:150–3.

Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367:1901–11.

Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care. 2008;12:R74.

Schortgen F, Girou E, Deye N, Brochard L. The risk associated with hyperoncotic colloids in patients with shock. Intensive Care Med. 2008;34:2157–68.

Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017;43:155–70.

 

Publications (26)
  • Hydroxyethyl starch solutions and patient harm

    Following the European Medicines Agency’s (EMA) suspension of the marketing authorisations of hydroxyethyl starch (HES) solutions across the European Union (EMA, 2018), Roberts et al., have written an open letter addressed to the World Health Organization (WHO) Director General seeking support for the suspension of HES solutions and expanding it to a worldwide ban.

  • Recruitment of extravascular fluid by hyperoncotic albumin

    In 1896 Ernest Starling published his hypothesis for fluid exchange, whereby fluid exchange exists mainly in the capillaries through a process of plasma ultrafiltration across semipermeable membranes (Starling, 1896). But is this 19th century theory something of the past?

Anmelden/Registrieren Maximieren Minimieren