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).
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
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?
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.
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The Coordination Group for Mutual Recognition and Decentralised Procedures (CMDh) endorse the suspension of hydroxyethyl-starch (HES) solutions, due to serious risks of kidney injury and death in certain patient populations.
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.
This article is a review and summary of the current opinion of albumin in fluid management.
A recent PRAC review has recommended suspension of marketing authorisations for HES solutions for infusion across the EU.
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