ALBUMIN-The Colloid Which Refuses to Go away .pptx

Albumin supplementation facts

1. ALBUMIN-THE COLLOID WHICH REFUSES TO GO AWAY Dr Tatikonda Chandra Mouli MD (DNB) DM critical care

2. Greetings from Dept of critical care IMS & SUM hospital , Bhubaneshwar

3. This is for two set of audience Who thinks albumin is best Who thinks albumin is worst

4. Should albumin infusion target serum albumin levels ? Albumin less effective as volume expander? Role albumin in AKI Use of Albumin in sepsis-A futile show ? Is contraindicated in circulatory overload ? Albumin and liver cirrhosis Is Albumin harmful in TBI? Paracentesis & Plasma exchange

5. Proportion of all Resuscitation episodes given in 2007 -2014 in 84 ICU’S 6S trial Perner . NEJM 2012;367:124-34. doi : 10.1056/NEJMoa1204242

6. Human Albumin Edwin Joseph Cohen Albumin is only synthesised in liver (200 mg/kg/day)and is not stored in liver Half life is about 18-21 days Molecular weight of albumin is 66.5 KDa. NORMAL LEVEL OF ALBUMIN IN BODY IS 3.5 – 5.5 g/dl

7. ROLE OF ALBUMIN IN ICU Hypoalbuminemia Resuscitation fluid Replacement fluid for plasma exchange Sepsis and septic shock As an adjunct to Frusemide Liver Disease  Hepatorenal syndrome  Paracentesis  spontaneous bacterial peritonitis with renal failure

8. Albumin in Resuscitation 16 ICUs in Australia November 2001 – June 2003 Comparing 4% albumin to 0.9% sodium chloride . Excluded post-op cardiac surgery, liver transplantation, burns 6997 patients randomized

9. Most common terms used in ICU Give some 100ml soda bicarbonate Give some fluids Thoda albumin dedo

10. Should albumin infusion target serum albumin levels

11. ALBIOS Trial 1 00 ICU in Italy August 2008 to February 2012 severe sepsis 1818 participants 20% albumin solution with crystalloid fluid compared to crystalloid fluid alone Target Serum Albumin > 3g/L Excluded TBI patients

12. EARSS France 2011 Septic shock patients with in 6hrs 20% albumin Vs 0.9% NS, 8 th hourly for 3days 393 Vs 393 subjects No Mortality benefit (24.1% Vs 26.3%)

13. Albumin less effective as volume expander? Albumin 1:1.4 and colloids 1:1.2 ALBIOS trial early vasopressor stoppage and Less Cumulative fluid requirement

14. Role albumin in preventing AKI ? Chronic Liver Disease to prevent HRS Yes Septic shock  Albios Trial No No evidence of worsening renal parameters

15. Use of Albumin in sepsis-A futile show ? Increases the plasma oncotic pressure Vasopressor free days (ALBIOS) SAFE – Mortality benefit in severe sepsis With these borderline results still albumin refuses to go away Vincent et al. Critical Care 2014, 18:231

16. 308 patients Cirrhotic with sepsis-induced hypotension 5% albumin Vs 0.9% saline

17. Is contraindicated in circulatory overload ? 1. Albumin improves the effects of diuretics (Albumin binds to diuretics) Albumin + IV frusemide in hypoalbunemia with ALI Martin et al Critical care medicine 2005,33 1681 to 1687 2. Albumin administration improves fluid removal during RRT Macerdo etal critical care 2021 3) Cirrhotic cardiomyopathy Improves oxygenation Increased negative balance Albumin Vs Saline Decrease hypotension 7% Vs 15%(p-0.002) Fluid removal 8.27 ml/kg/hr Increased cardiac index by 10% Umgelte et al,, Germany

18. Albumin and liver cirrhosis LVP (large volume paracentesis) >5lt  PICD 8gm/L- decreased shock, hyponatremia, AKI, encephalopathy and mortality SBP ( spontaneous bacterial peritonitis) decreased Type-1 HRS by 60% and decreased mortality HRS-AKI (hepatorenal syndrome) Metanalysis by 9 RCT, 1231 pts

19. Is Albumin harmful in TBI Recollect the SAFE trial Albumin used was 4% Any hypotonic solution cause inc ICP

20. Is Albumin harmful in TBI Criticism  lower osmolarity might contribute ( Osm - 266-267 mosm /L) BASICS A 40yrs old male a known case of CLD with HE with ascites and coagulopathy had motor vehicle accident admitted to ER with low GCS after resuscitation phase he had shifted to MICU for further management ? Albumin can be given to prevent HRS AKI Can albumin given for Cirrhosis What stopping you???

21. Is Albumin harmful in TBI Hypo osmolar solutions worsens outcomes in TBI May be harmful Or May not be

22. Albumin Antioxidant Controversies- excess albumin decreases effect of Tacrolimus  Graft rejection Newer Albumin Molecules Super Albumin Long-term Use of Albumin Antibiotics and Albumin (INCIFER Study) ANSWER study- positive trial MATCH study No benefit UK attire study

23. Albumin Albumin role in ACLD (ASIA Trial  On going trial) Albumin Dialysis  Plasmapheresis GBS, TTP MELD >30 improve outcomes AARC>11 Financial concerns The COASST study- - Journal of Critical Care (2007) 22, 197– 203

24. Story of albumin

25. "Science is built of facts as a house is built of bricks; but an accumulation of facts is no more science than a pile of bricks is a house“ Create your own reality

26. Unfathomed areas about Role of albumin Chronic kidney disease Hepatopulmonary syndrome Sarcopenia Procedures like TIPS Dose of albumin to be infused

27. Take Home 1. Should albumin infusion target serum albumin levels ? NO 2. Albumin effective as volume expander? Yes, but as compared to other colloids 3. Role albumin in preventing AKI ? Yes HRS 4. Use of Albumin in sepsis-A futile show ? Benefit in septic shock

28. Take Home 5. Is contraindicated in circulatory overload ? No 6. Albumin and liver cirrhosis ? Yes (specific to LVP,SBP,HRS) 7. Is Albumin harmful in TBI? Needs further investigations 8. Paracentesis & Plasma exchange Yes

29. Thank you