We read with interest the recent article by Cochrane Injuries Group Albumin reviewers on the Human Albumin administration in critically ill patients (BMJ No. 7153, 25 July 1998) together with the accompanying editorial in the same journal 1, 2
The Authors in the above article concluded that human albumin should not be given anymore outside the context of rigorously conducted randomised controlled trials. They have shown that albumin administration in critically ill patients with hypovolaemia, burns or hypoalbuminaemia may increase mortality.
In the early part of 1997 we carried out an audit on the use of human albumin solution (HAS 4.5% and 20%), following a dramatic increase in usage in our Trust. Our audit showed 4.5% HAS was used non-specifically in patients with low serum albumin levels in a variety of clinical conditions (including an occasional request for 500 ml only) and 20% HAS was used mainly in patients with chronic liver disease.
During this audit we did a literature search on the indication for the use of human albumin solution including the product data from Zenalb (BPL) 3 - 7. We found little conformity and often conflicting advice given on clinical indications in all the literature reviewed. Comparison between four European Countries which had agreed National indications for use of HAS also showed considerable variation with two indications only in Country A ranging to 12 clinical indications given in Country D. The amount of albumin used per 1000 population also varied widely (from 109 - 810 gms/year)5.
Our Literature search has shown ineffective use of HAS in the following clinical situations:
As nutritional supplementation,volume replacement if blood loss is less than 30% of total blood volume, early treatment (less than 24 to 48 hours) of burns and thermal injuries, albumin replacement in chronic protein loss due to enteropathy, cirrhosis and nephrosis,and in low volume paracentesis. We have established local clinical indications for the use of HAS both for 4.5% and 20% taking into the considerations of non-indications given above. However, in the light of the Cochrane paper we may now need to review the clinical indications on the use of HAS.
The inappropriate use of this product may thus be due to lack of universal and specific clinical indications. Although albumin administration may be harmful in certain categories of patients, favourable effects of albumin administration in some patients may have been obscured in the Cochrane analysis and the use of albumin solution should not be stopped. It is important instead that a concerted effort is made to identify those patients who may benefit from albumin administration.
References
1 Martin Offringa. Excess Mortality after human albumin administration in critically ill patients. BMJ 1998; 317:223-224.
2 Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systemic review of randomised controlled trials. BMJ 1998; 317:235-240.
3 ABC of Transfusion, Second Edition, BMJ Publishing Group 1992.
4 Handbookd of transfusion medicine, United Kingdom Blood Transfusion Services (1996).
5 Therapy with plasma and albumin production and clinical use. Proceedings of the third SIITC-AICT symposium for European co-operation-Rome 6th June 1992.
6 Hastings GE, Wolf PG. The Therapeutic use of Albumin. Arch fam Med 1992; 1(2), 281 - 287.
7 Zenalb Human Albumin Solution 4.5% Naturally, Beyond Simple Volume EXPANSION Bio Products Laboratory, Dagger Lane, Elstree, Herts, U.K. (August 1996).
K. H. SHWE,
Consultant Haematologist.
M. BHAVNANI,
Consultant Haematologist.
Rapid Response:
audit of albumin usage
We read with interest the recent article by Cochrane Injuries Group Albumin reviewers on the Human Albumin administration in critically ill patients (BMJ No. 7153, 25 July 1998) together with the accompanying editorial in the same journal 1, 2
The Authors in the above article concluded that human albumin should not be given anymore outside the context of rigorously conducted randomised controlled trials. They have shown that albumin administration in critically ill patients with hypovolaemia, burns or hypoalbuminaemia may increase mortality.
In the early part of 1997 we carried out an audit on the use of human albumin solution (HAS 4.5% and 20%), following a dramatic increase in usage in our Trust. Our audit showed 4.5% HAS was used non-specifically in patients with low serum albumin levels in a variety of clinical conditions (including an occasional request for 500 ml only) and 20% HAS was used mainly in patients with chronic liver disease.
During this audit we did a literature search on the indication for the use of human albumin solution including the product data from Zenalb (BPL) 3 - 7. We found little conformity and often conflicting advice given on clinical indications in all the literature reviewed. Comparison between four European Countries which had agreed National indications for use of HAS also showed considerable variation with two indications only in Country A ranging to 12 clinical indications given in Country D. The amount of albumin used per 1000 population also varied widely (from 109 - 810 gms/year)5.
Our Literature search has shown ineffective use of HAS in the following clinical situations:
As nutritional supplementation,volume replacement if blood loss is less than 30% of total blood volume, early treatment (less than 24 to 48 hours) of burns and thermal injuries, albumin replacement in chronic protein loss due to enteropathy, cirrhosis and nephrosis,and in low volume paracentesis. We have established local clinical indications for the use of HAS both for 4.5% and 20% taking into the considerations of non-indications given above. However, in the light of the Cochrane paper we may now need to review the clinical indications on the use of HAS.
The inappropriate use of this product may thus be due to lack of universal and specific clinical indications. Although albumin administration may be harmful in certain categories of patients, favourable effects of albumin administration in some patients may have been obscured in the Cochrane analysis and the use of albumin solution should not be stopped. It is important instead that a concerted effort is made to identify those patients who may benefit from albumin administration.
References
1 Martin Offringa. Excess Mortality after human albumin administration in critically ill patients. BMJ 1998; 317:223-224.
2 Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systemic review of randomised controlled trials. BMJ 1998; 317:235-240.
3 ABC of Transfusion, Second Edition, BMJ Publishing Group 1992.
4 Handbookd of transfusion medicine, United Kingdom Blood Transfusion Services (1996).
5 Therapy with plasma and albumin production and clinical use. Proceedings of the third SIITC-AICT symposium for European co-operation-Rome 6th June 1992.
6 Hastings GE, Wolf PG. The Therapeutic use of Albumin. Arch fam Med 1992; 1(2), 281 - 287.
7 Zenalb Human Albumin Solution 4.5% Naturally, Beyond Simple Volume EXPANSION Bio Products Laboratory, Dagger Lane, Elstree, Herts, U.K. (August 1996).
K. H. SHWE,
Consultant Haematologist.
M. BHAVNANI,
Consultant Haematologist.
Competing interests: No competing interests