Albumin ~clinical indication Speaker:樹金忠 2003/2/10 2019/5/26 intern 樹金忠
Mechanism of action/Effect Blood volume expander—70 to 80% of the colloid oncotic pressure of plasma. Antihyperbilirubinemic—Albumin is a transport protein that reversibly binds both endogenous and exogenous substances including bilirubin fatty acids, hormones, enzymes, drugs, dyes, and trace metals 2019/5/26 intern 樹金忠
2019/5/26 intern 樹金忠
2019/5/26 intern 樹金忠
2019/5/26 intern 樹金忠
Indications 2019/5/26 intern 樹金忠
General Consideration The benefit of administration of albumin to seriously ill patients is currently controversial. 2019/5/26 intern 樹金忠
A meta-analysis of randomized, controlled clinical studies of albumin use revealed excess mortality of approximately 6% (i.e., 1 excess death per 17 treated patients) combined groups of patients with hypovolemia, burns, or hypoproteinemia who received albumin either instead of or in addition to crystalloid solutions. Also, for each of these patient subgroups, the risk of death in the albumin-treated group was higher than in the comparison group. BMJ 1998; 317: 235-40. 2019/5/26 intern 樹金忠
使用規定 (1) 休克病人擴充有效循環血液量 A.休克病人至少已給生理鹽水或林格爾液等晶類溶液1000 mL後尚不能維持穩定血流動態，血比容（hematocrit）＞30%，或血色素（hemoglobin）＞10 gm/dL，須要繼續靜脈輸液時，宜優先使用合成膠類溶液，如dextran、hydroxyethylstarch、polyvinylpyrolidone等。若無上述合適製劑，可給白蛋白溶液，每一病人用量限50 gm（86/1/1）。 B. 70歲以上老人及二歲以下幼兒或併有心衰竭的休克病人，無法忍受太多靜脈輸液時，可一開始即使用白蛋白溶液，每一病人用量限50 gm。 2019/5/26 intern 樹金忠
(2) 病危、有腹水或水腫併有血清白蛋白濃度偏低病人 A.血清白蛋白濃度低於 2.5 gm/dL b. 腎病症候群（嚴重蛋白尿致血清白蛋白下降），每日最多用量限25 gm。 c. 嚴重燒燙傷。 d. 肝移植。 2019/5/26 intern 樹金忠
a. 呼吸衰竭使用人工呼吸器超過三天，仍無法脫離。 b. 嚴重肺水腫。 c. 大量肝切除（＞40%） B.血清白蛋白濃度低於 3.0 gm/dL a. 呼吸衰竭使用人工呼吸器超過三天，仍無法脫離。 b. 嚴重肺水腫。 c. 大量肝切除（＞40%） C.開心手術用於維持體外循環液，用量限 37.5 gm。 2019/5/26 intern 樹金忠
Accepted Hypovolemia (treatment) Hypoproteinemia (treatment) ------<25 g/l, and edema Med J Aust 1992; 157: 340-3 Hyperbilirubinemia, neonatal (treatment) Respiratory distress syndrome, adult (ARDS) (treatment adjunct) Cardiopulmonary bypass (treatment adjunct) 2019/5/26 intern 樹金忠
Nephrotic syndrome, acute (treatment adjunct) Accepted Ascites (treatment adjunct)1 Nephrotic syndrome, acute (treatment adjunct) .Hemodialysis--susceptible to shock and hypotension Pancreatitis (treatment adjunct) or Intra-abdominal infections (treatment adjunct) Liver failure, acute (treatment adjunct) 2019/5/26 intern 樹金忠
Accepted Red blood cell resuspension Plasmapheresis 2019/5/26 intern 樹金忠
Unaccepted Chronic cirrhosis or nephrosis Malnutrition Given in excessive amounts, albumin may increase the catabolism of endogenous albumin. DICP 1984; 18: 202-12. Surg Gynecol Obstet 1986; 163: 359-62. 2019/5/26 intern 樹金忠
Contraindication 1.allergy 2.heart failure 3.severe anemia 2019/5/26 intern 樹金忠
BMJ 1998;317:235-240 Human albumin administration in critically ill patients: systematic review of randomised controlled trials 2019/5/26 intern 樹金忠
A systematic review of cohort studies meeting specified criteria estimated that for each 2.5 g/l decrement in serum albumin concentration the risk of death increases by between 24% and 56%. J Clin Epidemiol 1997;50:693703. 2019/5/26 intern 樹金忠
Results For each patient category the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death after albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), For burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia it was 1.69 (1.07 to 2.67). 2019/5/26 intern 樹金忠
Result Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. 2019/5/26 intern 樹金忠
Conclusions There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials. 2019/5/26 intern 樹金忠
A plausible mechanism Furthermore, albumin has been shown to distribute across the capillary membrane, a process that is accelerated in critically ill patients . It has been suggested that increased leakage of albumin into the extravascular spaces might reduce the oncotic pressure difference across the capillary wall, making oedema more likely. 2019/5/26 intern 樹金忠
2019/5/26 intern 樹金忠
A plausible mechanism Is there by which human albumin might increase mortality? Albumin is used in hypovolaemia and hypoalbuminaemia because it is believed to be effective in replacing volume and supporting colloid oncotic pressure. However, albuminis also believed to have anticoagulant properties, inhibiting platelet aggregation and enhancing the inhibition of factor Xa by antithrombin III. Such anticoagulant activity might be detrimental in critically ill patients, particularly those with haemorrhagic hypovolaemia. 2019/5/26 intern 樹金忠