Letters

Albumin controversy continues

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7181.464 (Published 13 February 1999) Cite this as: BMJ 1999;318:464

Meta-analysis has affected use of albumin

  1. Richard Patey, Specialist registrar in paediatrics,
  2. Georgina Wilson, Senior house officer in paediatrics,
  3. Tony Hulse, Consultant paediatrician
  1. Paediatric Department, Maidstone Hospital, Maidstone, Kent ME16 9QQ
  2. Dalhousie University, Halifax, Nova Scotia, Canada B3H 2Y9

    EDITOR—With the recent Cochrane Injuries Group meta-analysis regarding albumin1 and subsequent correspondence in mind, we undertook a postal survey of paediatric departments in the South East Thames region. We asked clinicians which fluid (crystalloid, albumin, or other colloid) would be used in a variety of scenarios, before and after 25July 1998,in light of the meta-analysis. Altogether 12of 13departments replied, which equals a 92% response rate (table).

    Results of postal survey on use of colloids in paediatric wards

    View this table:

    We found that all 12would use crystalloid for 5% dehydration after gastroenteritis, both before and after 25July. Crystalloids are favoured over “other colloids” for all indications. Recent publications have influenced routine clinical practice, reducing clinicians' willingness to use albumin, but most departments have not made changes. Only in trauma resuscitation has there been a substantial shift away from albumin to crystalloid, and in meningococcal disease clinicians are still regularly using albumin. This suggests that published reservations2 regarding the meta-analysis are borne out in clinical practice.

    References

    Lack of efficacy shows that treatments do not work

    1. Stephen Workman, Associate professor (sworkman{at}IS.Dal.Ca)
    1. Paediatric Department, Maidstone Hospital, Maidstone, Kent ME16 9QQ
    2. Dalhousie University, Halifax, Nova Scotia, Canada B3H 2Y9

      EDITOR—Times are tough for those involved in critical care medicine and for the entire concept of normalising haemodynamic variables as an integral aspect of caring for critically ill patients. First, the Swan-Ganz catheter comes under attack for increasing mortality.1 Next, albumin, long the white knight of fluid resuscitation, is shown also to increase mortality.2

      Although both studies, which also have important financial implications, are based on the best available information, the respective research teams have come under immediate and sustained attack. Many doctors claim that they possess special knowledge and skills such that the results do not apply to them. Others claim that their unique subgroup of patients was not included in the studies. Such claims can be supported when treatment is clearly efficacious, such as during the introduction of penicillin in the 1940s, but it is difficult to understand how doctors can tell at the bedside if a treatment increases or decreases the relative mortality of a disease process by only 5% or 10%—changes that are almost certainly below the limit of perceptibility at the bedside. Doctors who believe they can discern such small changes are probably deluding themselves.

      What is particularly disturbing is the absence of a positive impact on survival with either of these two treatments. If they were as essential and as effective as some claim, this would have been borne out in studies. Such a lack of efficacy cannot be explained beyond the obvious fact that the treatments do not work and are, if anything, harmful.

      Unless currently used but unproved practices are completely effective, the transition to evidence based practice will require the slaughter of some of medicine's sacred cows, but it is important to remember that they are being slaughtered to save the lives of patients.

      References

      View Abstract

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