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This educational handbook provides an update on recent developments in the field of fluid therapy, including the latest evidence for albumin across different clinical settings.
Fluid therapy is vital in the treatment of critically ill patients, and in patients with liver disease or undergoing surgery. Replenishment of the intravascular volume is required when large volumes of blood are lost. This can be achieved with crystalloids, such as saline, or colloids, which can be natural (for example, albumin) or synthetic (for example, hydroxyethyl starch (HES) or gelatin). Since the first edition of this handbook was published in 2013, there has been ongoing debate regarding which fluid is best, despite accumulating evidence that some fluids, notably HES, can be harmful to patients. The choice of fluid in any given scenario is influenced by physician preference and this guide is intended to provide up-to-date information based on the rapidly evolving evidence base.
Crystalloids are widely used due to their low cost and availability; however, recent data show that they are sometimes insufficient for attaining haemodynamic thresholds in critically ill patients. In addition, positive fluid balance might occur in patients who receive high volumes of crystalloids, which is a significant risk factor for adverse effects including cardiovascular complications and pulmonary oedema. Importantly, recent evidence from the SWIPE trial showed that hyper-oncotic, 20% albumin delivered less fluid, sodium and chloride than hypo-oncotic, 4% albumin. International guidelines from the Surviving Sepsis Campaign recommend crystalloids for initial resuscitation followed by albumin as the colloid of choice if crystalloids are insufficient. Due to the risks associated with HES and gelatin, the use of these synthetic colloids is cautioned against in severe sepsis. Adverse effects of these fluids have also been observed in other patients, such as those undergoing surgery. HES is associated with increased mortality and renal injury, as shown in the large randomised trials, CHEST and 6S. These known risks prompted a review of HES products by the European Medicines Agency in 2013 and again in 2018. On both occasions, it was recommended that all HES products be withdrawn due to serious concerns over safety. However, those recommendations were overturned and HES solutions were permitted to remain on the market, with additional restrictions imposed on their use to ensure patient safety. The continuing availability of HES products on the European market remains subject to the results of large post-approval trials in trauma (TETHYS) and surgery (PHOENICS) that must demonstrate an appropriate level of patient safety.
Evidence continues to highlight the safety and effectiveness of albumin solutions. Albumin therapy is firmly established in liver disease and evidence from the recent ANSWER trial showed that long-term albumin administration in patients with decompensated cirrhosis improves survival. This trial also demonstrated the pharmacoeconomic benefits of albumin, with overall costs decreased in patients who received standard medical treatment plus albumin compared with standard medical treatment alone.
The favourable cost-effectiveness was due to the reduced incidence of complications and hospital admissions in the long term. Further data from Spain and Germany have also indicated that albumin appears to be more cost-effective than saline and gelatin across a spectrum of liver diseases. European and numerous national guidelines recommend albumin as an adjunct to paracentesis for patients with cirrhotic ascites and for those with spontaneous bacterial peritonitis or hepatorenal syndrome.
Since the first edition of this handbook, evidence for the use of albumin in surgery has increased and there are conceptual grounds for the benefits of albumin administration in surgical patients with hypoalbuminaemia that need to be further explored. In addition, there is increasing awareness of the non-oncotic benefits of albumin, including antiinflammatory effects, stabilisation of the endothelium and maintenance of the glycocalyx, which is vulnerable to damage in patients with critical illness.
The information contained in this educational guide is intended to highlight the key benefits and shortcomings of different fluid therapies, with a focus on the role of albumin in the intensive care unit and the operating room. By summarising the latest evidence, the goal is to support healthcare personnel in their daily practice and decision-making, to help ensure the best outcomes for patients in the often life-threatening circumstances where volume resuscitation is required.