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LETTERS: Andy Petros, Margrid Schindler, Christine Pierce, Steven Jacobe, Quen Mok, Mark R Nel, Simon Nadel, Steven Marriage, Claudine De Munter, Joseph Britto, Parviz Habibi, Michael Levin, M Kaag, F A N Zoetmulder, F Andrew I Riordan, Andrew Williams, Alistair P J Thomson, Neil Soni, Neville W Goodman, R J Beale, D L A Wyncoll, A McLuckie, J D Frame, N Moiemem, Iain Chalmers, P G Lawler, G A Morgan, K H Shwe, M Bhavnani, and Ian Roberts Human albumin administration in critically ill patients BMJ 1998; 317: 882 [Full text]

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Albumin traduced

Peter Horsey   (1 October 1998)

Weak response

O Dearlove, A Sharples, S Maguire   (6 October 1998)

Albumin traduced 1 October 1998
Peter Horsey Send response to journal: Re: Albumin traduced	Editor There are only two explanations for the conclusions arrived at by the authors of the Cochrane Review (1)- either that albumin was given in excessive amounts or that the commercial processing it undergoes makes it toxic. Several of the letters published last week (September 26) call for expert appraisal of the evidence on which it was based. As a start I suggest that attention should be directed to the numerous papers published by the Detroit group, all based on the same 52 patients, five of which are in the reference list of the review. Lucas et al (2) gave the 27 patients in the albumin group 24% albumin during resuscitation followed by a dose of 150 grams a day for five days post operatively, this dose being "selected to restore albumin levels to normal". Simultaneously whole blood, fresh frozen plasma and Ringer/lactate were given in amounts greater than the control group and resulting in a weight gain of about 10kg in the first 48 hours. This produced the highest relative risk of death (13.93) of all the references quoted. The conclusions of this group on the perceived malign effects of albumin on the heart, lungs, kidneys and the coagulation system have been uncritically accepted for over twenty years and have been quoted by a former Director of the Scottish National Blood Transfusion Service (3) and endorsed in the most recent Americal textbook of perioperative transfusion medicine (4) as well as inclusion in the evidence of the Cochrane review. Margarson and Soni (5) in a recent review mention the possible toxic effect of commercially produced albumin due to aluminium and other metals and this issue needs to be investigated. WereI to need a massive transfusion I would happily receive 5% albumin in volumes no greater than the plasma removed from the red cells transfused. Should I be given 24% albumin in order to maintain "normal" levels of my plasma albumin concentration I might, like Dr Chalmers, think of suing. On the other hand I might be dead. Peter Horsey Honorary Consultant Anaesthetist Shackleton Department of Anaesthetics Southampton General Hospital SO16 6Y References 1 Cochrane Injuries Group Reviewers. Human albumin in critically ill patients: systematic review of randomised controlled trials BMJ 1998;317:235-40 (25 July.) 2 Lucas CE, Weaver D, Higgins RF, Johnson SD, Bouwman DL effect of albumin versus non-albumin resuscitation on plasma volume and renal excretory function. J Trauma 1978;18:565-70. 3 Cash JD in Haemostasis and Thrombosis Eds AL Bloom DP Thomas Churchill Livingstone, London 1981. 4 Perioperative Transfusion Medicine Eds DP Spiess, R B COUNTS, S A Gould Williams & Wilkins, Baltimore 1998. 5 Margarson M P, SONI N. Serum albumin: touchstone or totem? Anaesthesia 1998;53:789-803.
Weak response 6 October 1998
O Dearlove, Department of Paediatric Anaesthesia Royal Manchester Children's Hospital, A Sharples, S Maguire Send response to journal: Re: Weak response	Contributors have argued cogently why the Cochrane Group should not have drawn the conclusions they did with the data available. Ian Roberts replies only that none have brought foward evidence that refutes his conclusions so they must stand. A jurist (Scrutton LJ) commented that if one discredited a witness, it does not mean that one has established the opposite to what the witness said, it is just that there is now no evidence on the subject. I think we have arrived at the same position with the use of albumin: the case is still before the courts. Having printed the article and published the letters - which we know further the peer-review process, it is a pity the Editor did not further encourage Roberts to address some of the issues posed in the letters, rather than allow him just to restate his position. Nonetheless we can conclude in like manner to Ian Roberts that since Roberts has brought forward no evidence to refute the criticism of his study, the criticisms still stand. Oliver Dearlove FRCA Consultant Anaesthetist Andrew Sharples FRCA Consultant Paediatric Intensivist S Maguire MB BCh Specialist Registrar