Maintenance of the colloid osmotic pressure (cop)

Maintenance of the colloid osmotic pressure (COP)

• Maintenance of the colloid osmotic pressure (COP)

• Binding and transport, particularly of drugs

• Free radical scavenging

• Acid base balance

• Anti-coagulatory effects

• Affects vascular permeability

At the time of hospital admission, 20% of patients have hypoalbuminemia

• At the time of hospital admission, 20% of patients have hypoalbuminemia

Decreased or abnormal synthesis synthesis.

• Decreased or abnormal synthesis synthesis.

• hepatitis, CLD, PEM,IBD

• Increased catabolism (major injuries, malignancy,fever,pancreatitis)

• Increased loss: nephrotic syndrome,burns,gut losses,hemorrhage & post surgical procedures

• Redistribution: Haemodilution (CHF,ARDS, overhydration )

• Increased capillary permeability (sepsis, SIRS stress response)

Decreased hepatic production due to chronic illness

• Decreased hepatic production due to chronic illness

• Redistribution into the extravascular space

• Dilution due to fluid administration

Low serum albumin levels are an important predictor of morbidity and mortality. A meta-analysis of cohort studies found that, with every 10 g/L decrease in serum albumin, mortality was increased by 137% and morbidity increased by 89%

• Low serum albumin levels are an important predictor of morbidity and mortality. A meta-analysis of cohort studies found that, with every 10 g/L decrease in serum albumin, mortality was increased by 137% and morbidity increased by 89%

• The study also showed increased in ICU stay by 28% & hospital stay by 71%

• ________________________________

• from Annals of Surgery

• Posted 03/17/2003

• Jean-Louis Vincent, MD, PhD, FCCM, Marc-Jacques Dubois, MD, Roberta J. Navickis, PhD, Mahlon M. Wilkes, PhD

• Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium, and †Hygeia Associates, Grass Valley, California, U.S.A

HX

• HX

• Gather past medical history for a history of liver or renal failure, hypothyroidism, malignancy, and malabsorption.

• Evaluate the patient for appropriate dietary intake.

• Seek potential causes of acute or chronic inflammation that could explain the low albumin levels

Head, eyes, ears, nose, and throat

• Head, eyes, ears, nose, and throat

• Facial edema, macroglossia, parotid swelling, conjunctival icterus, temporal wasting

• Integumentary

• Loss of subcutaneous fat, delayed wound healing, dry coarse skin, painful dermatoses, peripheral edema, thin hair, spider angiomas, palmar erythema, jaundice

• Cardiovascular - Bradycardia, hypotension, cardiomegaly

Respiratory: gynecomastia,signs of pleural effusion

• Respiratory: gynecomastia,signs of pleural effusion

• GIT: ascitis, hepatosplenomegaly

• Musculoskeletal: wasting of mscles

• Neurological: asterixis, encephalopathy

• Genitourinary: testicualr atrophy

Malnutrition: Lymphocyte count and BUN are decreased. Transferrin, prealbumin, and retinol-binding protein have shorter half-lives compared with alubmin so it reflects short time change of PEM.

• Malnutrition: Lymphocyte count and BUN are decreased. Transferrin, prealbumin, and retinol-binding protein have shorter half-lives compared with alubmin so it reflects short time change of PEM.
• Inflammation: CRP & ESR are elevated.
• Nephrotic syndrome: The 24-hour urine collection contains more than 3 g of protein in 24 hours.
• Cirrhosis: LFT (transaminase levels) may be elevated or normal in patients who are cirrhotic. hepatitis screening, may be needed.
• Malabsorption: Fecal fat studies including Sudan qualitative stain for fat, 72-hour quantitative fecal fat collection, and fecal a-1-antitrypsin clearance are needed.

Liver US

• Liver US

• Small bowel series for mucosal abnormalities

• CXR ? Chest infection ass. With pleural effusion

• Echocardiography for CHF

Liver biopsy

• Liver biopsy

• Kidney biopsy

Should be focused on the underlying cause

• Should be focused on the underlying cause

• Simply replacing albumin intravenously has generally been ineffective

Indicated

• Indicated

• Following large volume paracentesis

• Nephrotic syndrome resistant to potent diuretics

• Volume/Fluid replacement in plasmapheresis

• Serum albumin <2.0 g/dl

• Labile pulmonary, cardiovascular status

• Extensive burns ( >15%)

• Plasma exchange

• Intraoperative fluid requirement > 5-6 L in adults

• Premature infant undergoing major surgery

Possibly indicated

• Possibly indicated

• Adult respiratory distress syndrome

• Ovarian hyperstimulation syndrome

• Cardiopulmonary bypass pump priming

• Fluid resuscitation in shock/sepsis/burns

• Neonatal kernicterus

Not indicated

• Not indicated

• Correction of measured hypoalbuminemia or hypoproteinemia

• Nutritional deficiency, total parenteral nutrition

• Pre-eclampsia

• Red blood cell suspension

• Simple volume expansion (surgery, burns)

• Wound healing

patients who are hypersensitive to albumin

• patients who are hypersensitive to albumin

• patients at special risk of developing circulatory overload (CHF,renal insuffciency,chronic anemia)

• Administration of albumin, leading to lower serum ionized calcium levels and causing myocardial depression

• Fluid overload

• Allergic reactions

• Misdiagnosis of ARDS secondary to pulmonary edema

Ninety cohort studies fulfilling the inclusion criteria were identified

• Ninety cohort studies fulfilling the inclusion criteria were identified

• The total number of patients in the 90 studies was 291,433 and the median number of patients per study was 281

• Forty-nine of the studies, with 200,413 patients, representing 69% of the total patient population, were published since 1998

Thirty studies involved hospitalized patients in general, 11 cardiac surgery, 12 noncardiac surgery, and 37 renal dysfunction.

• Thirty studies involved hospitalized patients in general, 11 cardiac surgery, 12 noncardiac surgery, and 37 renal dysfunction.

• . The median patient age across all included studies was 60 years (range 10-89)

• Forty-one included studies were prospective and 45 were retrospective.

• Four studies involved both prospective and retrospective components.

• Five studies were multicenter investigations.

pooled OR for these trials was 2.37 (CI 2.10-2.68). Thus, the odds of death were increased by 137% with each 10-g/L decline in serum albumin, and the effect was statistically significant

• pooled OR for these trials was 2.37 (CI 2.10-2.68). Thus, the odds of death were increased by 137% with each 10-g/L decline in serum albumin, and the effect was statistically significant

• Similarly, based on pooling within clinical indications, statistically significant increases in mortality odds of 102%, 116%, 180%, and 148% were observed for the hospitalization (OR 2.02; CI 1.52-2.70), cardiac surgery (OR 2.16; CI 1.47-3.16), noncardiac surgery (OR 2.80; CI 2.18-3.58), and renal dysfunction (OR 2.48; CI 2.11-2.91) categories, respectively.

Hypoalbuminemia was also an independent predictor of morbidity across all studies

• Hypoalbuminemia was also an independent predictor of morbidity across all studies

• The pooled OR for morbidity among all 18 studies assessing this endpoint was 1.89 (CI 1.59-2.24), indicating a statistically significant 89% increase in odds of complications corresponding to a 10-g/L reduction in serum albumin.

Significant increases in morbidity odds of 178%, 52%, 73%, and 102% were documented respectively among the subsets of studies involving hospitalization (OR 2.78; CI 1.30-5.98), cardiac surgery (OR 1.52; CI 1.12-2.04), noncardiac surgery (OR 1.73; CI 1.67-1.79), and renal dysfunction (OR 2.02; CI 1.48-2.74).

• Significant increases in morbidity odds of 178%, 52%, 73%, and 102% were documented respectively among the subsets of studies involving hospitalization (OR 2.78; CI 1.30-5.98), cardiac surgery (OR 1.52; CI 1.12-2.04), noncardiac surgery (OR 1.73; CI 1.67-1.79), and renal dysfunction (OR 2.02; CI 1.48-2.74).

Hypoalbuminemia was a significant independent predictor of prolongation in both ICU and hospital stay. Length of ICU stay was a subject of three included studies.[60, 78, 84] The pooled OR for ICU stay was 1.28 (CI 1.16-1.40), indicating a significant 28% increase in odds for prolonged ICU stay per 10-g/L decrement in serum albumin.

• Hypoalbuminemia was a significant independent predictor of prolongation in both ICU and hospital stay. Length of ICU stay was a subject of three included studies.[60, 78, 84] The pooled OR for ICU stay was 1.28 (CI 1.16-1.40), indicating a significant 28% increase in odds for prolonged ICU stay per 10-g/L decrement in serum albumin.

• OR and CI estimates for prolonged hospital stay were available from four included studies.[1, 39, 60, 78] The corresponding pooled OR was 1.71 (CI 1.33-2.21), revealing a significant hypoalbuminemia-related increase of 71% in odds of prolonged hospital stay.

Controlled Trials

• Controlled Trials

• Nine prospective controlled trials with 535 total patients

• The median number of patients per trial was 38 (range 24-219). Seven of the trials were randomized.[111, 114-119]

• Four trials involved pediatric patients.[111-113, 116] For the adult studies the median patient age was 59 years (range 47-71). The median duration of follow-up for both adult and pediatric trials was 26 days (range 5-150).

Pooled morbidity

• Pooled morbidity

• the pooled OR for occurrence of one or more complications in individual patients was 0.74 (CI 0.36-1.49). Thus, morbidity was lower among albumin recipients, but the effect was not statistically significant. The pooled odds ratio was similar after exclusion of the two nonrandomized trials (OR 0.81; CI 0.41-1.60).[112, 113] There was no evidence of publication bias (P = .367). Among all control group patients, 48% (125/262) experienced one or more complications.

The effect of surgical procedures on serum albumin concentration.

• The effect of surgical procedures on serum albumin concentration.

• Chirurgia (Bucur). 2008 Jan-Feb;103(1):39-43.

• Alberti LR, Petroianu A, Zac RI, Andrade JC Jr.

• Alfa Institute of Gastroenterology of the Hospital of Clinics of the Federal University of Minas Gerais, Brazil.

• PURPOSE: To assess the effect of surgical trauma on serum albumin concentration during the immediate postoperative period

• METHODS: 200 consecutive adult patients submitted to elective major surgeries (Group 1) and to medium size surgeries (Group 2) were identified according to gender, age and skin color.

• Conclusion:There was a reduction in serum albumin in Group 1 (p < 0.0001) and Group 2 (p < 0.0001), with no difference between gender or skin colors for major surgeries. However, women showed a lower reduction than men in serum albumin in medium-sized surgeries. In medium-sized surgeries, black patients had the lowest reduction in albuminemia. The greater reduction in albuminemia occurred in patients older than 65 years old

Replacement of albumin after abdominal surgery

• Replacement of albumin after abdominal surgery

• K Mahkovic Hergouth1 and L Kompan2

• 1Institute of Oncology, Ljubljana, Slovenia

• 2Clinical Center, Ljubljana, Slovenia

• from 27th International Symposium on Intensive Care and Emergency Medicine Brussels, Belgium. 27–30 March 2007

• Critical Care 2007, 11(Suppl 2):P405doi:10.1186/cc5565.

• Method: retrospectively studied 76 successive patients operated on in the abdomen at the Oncologic Institute in Ljubljana in 1997/98 (group 1 – postoperative hypoalbuminemia treated with 20% albumin solution) and in 2000/01 (group 2 – no albumin treatment),

• Conclusion:

• In both groups there was very significant drop of albumin concentration in the first week after surgery . In group 2 albumin concentrations were very significantly lower than in group 1 until the fifth postoperative day

• The difference diminished after the sixth postoperative day

• There was negative correlation between the postoperative albumin concentration and the duration of surgery

• found no difference in the postoperative complication rate (surgical or medical), length of stay and mortality between the groups.

AIDS Res Hum Retroviruses. 2007 Oct;23(10):1197-200.Links

• AIDS Res Hum Retroviruses. 2007 Oct;23(10):1197-200.Links

• Graham SM, Baeten JM, Richardson BA, Wener MH, Lavreys L, Mandaliya K, Ndinya-Achola JO, Overbaugh J, McClelland RS.

• Department of Medicine, University of Washington, Seattle, Washington 98104, USA. [e-mail]

• A decrease in albumin of over 10% was associated with a 3.5-fold increase in the risk of progressing to a CD4 count <200

• A greater decrease in albumin levels accompanying HIV-1 acquisition may be a marker for changes in early infection associated with more rapid disease progression.

Crit Care. 2005;9(6):649-50.

• Crit Care. 2005;9(6):649-50.

• Is albumin administration in the acutely ill associated with increased mortality?

• Vincent JL, Sakr Y, Reinhart K, Sprung CL, Gerlach H, Ranieri VM; 'Sepsis Occurrence in Acutely Ill Patients' Investigators.

• Department of Intensive Care, Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium. [e-mail]

• METHODS: In a cohort, multicenter, observational study, all patients admitted to one of the participating ICUs between 1 May and 15 May 2002 were followed up until death, hospital discharge, or for 60 days. Patients were classified according to whether or not they received albumin

RESULTS:

• RESULTS:

• Of 3,147 admitted patients, 354 (11.2%) received albumin and 2,793 (88.8%) did not. Patients who received albumin were more likely to have cancer or liver cirrhosis, to be surgical admissions, and to have sepsis. They had a longer length of ICU stay and a higher mortality rate, but were also more severely ill, as manifested by higher simplified acute physiology score (SAPS)

• ICU and hospital mortality rates were higher in the patients who had received albumin than in those who had not (34.8 versus 20.9% and 41.3 versus 27.7%, respectively,

Conclusion:

• Conclusion:

• Albumin administration was associated with decreased survival in this population of acutely ill patients. Further prospective randomized controlled trials are needed to examine the effects of albumin administration in sub-groups of acutely ill patients.

Cochrane Database Syst Rev. 2000;(2):CD001208.Links

• Cochrane Database Syst Rev. 2000;(2):CD001208.Links

• Cochrane Database Syst Rev. 2002;(1):CD001208.

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

• Bunn F, Lefebvre C, Li Wan Po A, Li L, Roberts I, Schierhout G.

• Department of Epidemiology, Institute of Child Health, 30 Guilford Street, London, UK, WC1N 1EH. [e-mail]

• Cohort study

• CONCLUSIONS:

• There is no evidence that albumin administration reduces the risk of death in critically ill patients with hypovolaemia, burns or hypoalbuminaemia, and a strong suggestion that it may increase the risk of death.

Low serum albumin is an independent indicator of (poor) outcome in critical illness.

• Low serum albumin is an independent indicator of (poor) outcome in critical illness.

• There is no evidence that correcting hypoalbuminemia improves outcome, indeed therapeutic albumin administration may worsen outcome.

• Morbidity, mortality and length of stay were not influenced by albumin replacement.

• The use of albumin in the critically ill patient is not supported by scientific evidence.

• It is no more effective than other agents used in the treatment of hypovolaemia.

treatment of hypoalbuminaemia has no significant benefit. Efforts should be concentrated on correcting the underlying cause of disease to reverse hypoalbuminaemia.

• treatment of hypoalbuminaemia has no significant benefit. Efforts should be concentrated on correcting the underlying cause of disease to reverse hypoalbuminaemia.

• The use of albumin may cause death.

• The use of albumin without an indication is a waste for the resources