Does Albumin as Resuscitative Fluid in Sepsis Improve Mortality When Compared to Crystalloid?

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Authors: Laurie Bezjian Wallace, DO
Mike O’Callaghan Military Medical Center

Bottom Line Up Front
Utilizing albumin as resuscitative fluid in patients with sepsis demonstrated no difference in all-cause mortality when compared to crystalloid (System of Record ((SOR)) A: meta-analysis of randomized controlled trials [RCTs]). Administration of 300mL of 20% albumin did not significantly lower mortality rates at 28 days or 90 days post-administration (SOR B: single unblinded RCT).

Introduction
Crystalloid versus colloid fluid resuscitation in septic patients remains a topic of discussion within the critical care community. This article details a meta-analysis and RCT which address the outcomes of utilizing albumin as a resuscitative fluid in patients with sepsis.

Review of Literature
In a 2014 meta-analysis, 15 RCTs including 6998 patients with sepsis examined the effects of albumin-containing fluids versus all other fluids for resuscitation. Of those, 3225 patients received albumin of varying concentrations. Eligibility criteria included patients diagnosed with sepsis of any severity.[1]

Patients who were not in the albumin group received either crystalloid, gelofusine, or starch as controls. The outcomes addressed were all-cause mortality at the longest duration follow up possible to include 48 hours, 28 days, or 90 days. Of the 15 RCTs, only two reported data up to 90 days. As such, only the results from trials assessing outcomes at 28 days were incorporated into the meta-analysis.[1]

The data pooled amongst these trials showed albumin as a resuscitative fluid had no statistically significant effect on all-cause mortality in patients with sepsis when compared to other resuscitative fluids (RR: 0.94, 95% CI [0.87, 1.02] and RD: –0.01, 95% CI [-0.03, 0.01]).[1]

An additional study conducted in 2014 was an RCT which evaluated the effects of albumin and crystalloid versus crystalloid fluid alone in 1818 patients admitted to the intensive care unit. Patients included in the trial were at least 18 years old and met diagnostic criteria for severe sepsis within the previous 24 hours of admission.[2]

Patients in the albumin group received 300mL of 20% albumin and crystalloid solution at a rate that maintained a serum albumin concentration of at least 30 grams per liter. The crystalloid group received normal saline alone. The primary outcome measurement was death at 28 days post-administration with a secondary outcome of death at 90 days post-administration.[2]

At the 28 day point, 31.8% of patients assigned albumin and 32% of patients assigned crystalloid died (RR in the albumin group: 1.00, 95% CI [0.87 to 1.14]; P=0.94). At 90 days post-administration, 41.1% of the patients who received albumin and 43.6% of patients who received crystalloid died (RR: 0.94, 95% CI [0.85 to 1.05]; P=0.29). When compared to crystalloid alone, albumin did not have a statistically significant effect on lowering rates of mortality in septic patients at 28 days or 90 days post-administration.[2]

Conclusion
Albumin administration in patients diagnosed with sepsis does not demonstrate a statistically significant difference in mortality when compared to crystalloid resuscitative fluids.

References:

1. Jiang L, Jiang S, Zhang M, Zheng Z, Ma Y. Albumin versus other fluids for fluid resuscitation in patients with sepsis: a meta-analysis. PLoS One. 2014;9(12):e114666.

2. Caironi P, Tognoni G, Masson S, et al. Albumin Replacement in Patients with Severe Sepsis or Septic Shock. N Engl J Med. 2014; 370:1412-1421.