Sunday, January 26, 2020

Albumin in the Initial Resuscitation of Sepsis and Septic Shock.

Several days ago I posted a comment on @iculaughingrn's page when the cited meme was posted. I guess I need to be extremely careful with my wording because I wrote "Looks like $30 of not much evidence to support its routine use in resuscitation". 

We live in a world now where every word counts and some people in the comments section let me have it. I am under a microscope and therefore this post clarifies my thought process with guidelines to support. It's also important to recognize why we do what we do or don't do. I'm not going to dissect the different albumin studies at this juncture. Maybe later. 

Healthcare as a whole in the US at this time is not sustainable. This is why I am hopeful that the HAT cocktail which is extremely cheap is successful versus one of these -NIB or -MAB drugs that costs tens of thousands of dollars. Albumin, relative to crystalloids, is extremely expensive. We need to be cognizant of these things. 

I should have written "routine use in sepsis resuscitation". The CVICU population is a completely different beast although I would LOVE to see data for albumin being beneficial in that population. I have not seen it. The burn population is one that terrifies me so kudos to all of you practicing there. I do not know your literature. 
Many of you know I am not a big fan of guidelines but this is something I can agree with. Earlier in my career I routinely used albumin. Now, I rarely use it. During my entire fellowship, albumin was not a word that was uttered in the MICU unless you were referencing the lab value.
Ultimately, the guidelines state: "The absence of any clear benefit following the administration of colloid compared with crystalloid solutions in the combined subgroups of sepsis, in conjunction with the expense of albumin, supports a strong recommendation for the use of crystalloid solutions in the initial resuscitation of patients with sepsis and septic shock."

After the initial resuscitation, the clinician needs to be the clinician. Giving fluids arbitrarily to make the BP look pretty is not something I am a fan of. Some patients may need albumin, some may not. I rarely use it in my practice, though. Use your best clinical judgement. A hat tip to the authors. 

Levy, M. M., Evans, L. E.; Rhodes, A. The surviving sepsis campaign bundle: 2018 update. Crit. Care Med. 46, 997–1000 (2018).

- EJ




Link to Article

Link to FULL FREE PDF

Levy, M. M., Evans, L. E.; Rhodes, A. The surviving sepsis campaign bundle: 2018 update. Crit. Care Med. 46, 997–1000 (2018).

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