Albumin Use in Neurosurgical Critical Care
Study Objective: To examine the use of albumin in patients receiving neurosurgical intensive care.
Design: Survey and chart review of albumin use in neurosurgical intensive care units.
Setting: University of Kentucky Chandler Medical Center and American Brain Injury Consortium (ABIC).
Subjects: Thirty-eight patients who underwent neurosurgery at the University of Kentucky Chandler Medical Center; members of the ABIC.
Interventions: Chart review with attention to administration of albumin; mailed survey to 200 ABIC members.
Measurements and Main Results: Patients admitted to the neurosurgical intensive care unit at the University of Kentucky Chandler Medical Center over a 6-month interval were evaluated. Albumin, either 5% or 25%, was prescribed for approximately 25% of patients. The indications for use were vasospasm and maintenance of cerebral perfusion pressure. The response rate for the ABIC survey was 39%. Respondents stated that normal saline and albumin were both primary fluid choices for the treatment of vasospasm. Twenty-two percent reported a reduction in albumin prescribing following a formal warning statement issued by the Food and Drug Administration regarding the use of albumin in critically ill patients.
Conclusions: Chart review revealed the primary indications for albumin in the neurosurgical intensive care unit, and our survey data demonstrated the lack of consensus among neurosurgeons regarding their fluid of choice for neurosurgery indications. Prospective, randomized investigations comparing colloids to crystalloids in patients receiving neurosurgical intensive care are required to help define the role of albumin in neurosurgery patients.
Controversy continues regarding the use of albumin in critically ill patients. According to a report from 15 academic health centers, albumin was prescribed to reach a defined end point in most of the cases. Only one adverse event was reported in the 969 forms evaluated. Inappropriate indications for albumin accounted for 62% of total costs noted in the report. The study concluded that institutions must define and implement guidelines that will focus on a more cost-efficient use of albumin.
In 1998 the Cochrane Injuries Group analyzed 30 studies involving more than 1400 patients. It found an excess mortality in patients treated with albumin compared with crystalloids. The indications for albumin were hypovolemia, burn injury, and hypoalbuminemia. In the United States, approximately 26% of albumin is given to treat acute hypovolemia, and less than 1% reportedly is used to correct low serum albumin. Limitations of meta-analyses that use mortality as an end point for this controversy have been reviewed extensively. Others have reexamined albumin use in critically ill patients. A meta-analysis of randomized controlled trials found no effect of albumin on mortality. An investigation of spontaneous serious adverse event reports showed an incidence of 1.29 such events/10 doses of albumin. Two additional reviews of albumin use in critically ill patients found pulmonary edema, mortality, and length of stay to be unaffected by fluid choice. In 2000, the Cochrane Database Systematic Reviews presented studies of albumin in critically ill patients for a variety of indications. No advantage was found for albumin over other colloids or crystalloids in these analyses. In response to the 1998 Cochrane Review, the Food and Drug Administration (FDA) cautioned the entire medical community to consider carefully the meta-analysis findings and adopt prescribing patterns that adhere to accepted guidelines.
Neurosurgical intensive care patients have not been represented adequately in these analyses. The meta-analysis findings from patients with burns, hypoalbuminemia, or hypovolemia would not apply to indications for use in neurosurgery. Aggressive fluid protocols commonly are implemented to prevent secondary ischemia after subarachnoid hemorrhage or severe traumatic brain injury. Albumin is often a component of these regimens, which are designed to maximize hemodynamics and maintain cerebral perfusion pressure (CPP). There is no evidence that albumin is superior to crystalloids for hypervolemic therapies in patients treated by neurosurgeons. The University HealthSystem Consortium, a clinical alliance of 87 academic health centers that publishes evidenced-based guidelines, does not support albumin for these indications. Nevertheless, this organization acknowledges that nonrandomized trials have suggested benefits for colloids, such as albumin, in these circumstances.
Controversy regarding the mortality associated with albumin, together with the limited literature addressing albumin use for neurosurgery indications, prompted our investigation. We sought to determine the pattern of albumin prescribing and gather preliminary evidence of the extent to which albumin is used by neurosurgeons.
Study Objective: To examine the use of albumin in patients receiving neurosurgical intensive care.
Design: Survey and chart review of albumin use in neurosurgical intensive care units.
Setting: University of Kentucky Chandler Medical Center and American Brain Injury Consortium (ABIC).
Subjects: Thirty-eight patients who underwent neurosurgery at the University of Kentucky Chandler Medical Center; members of the ABIC.
Interventions: Chart review with attention to administration of albumin; mailed survey to 200 ABIC members.
Measurements and Main Results: Patients admitted to the neurosurgical intensive care unit at the University of Kentucky Chandler Medical Center over a 6-month interval were evaluated. Albumin, either 5% or 25%, was prescribed for approximately 25% of patients. The indications for use were vasospasm and maintenance of cerebral perfusion pressure. The response rate for the ABIC survey was 39%. Respondents stated that normal saline and albumin were both primary fluid choices for the treatment of vasospasm. Twenty-two percent reported a reduction in albumin prescribing following a formal warning statement issued by the Food and Drug Administration regarding the use of albumin in critically ill patients.
Conclusions: Chart review revealed the primary indications for albumin in the neurosurgical intensive care unit, and our survey data demonstrated the lack of consensus among neurosurgeons regarding their fluid of choice for neurosurgery indications. Prospective, randomized investigations comparing colloids to crystalloids in patients receiving neurosurgical intensive care are required to help define the role of albumin in neurosurgery patients.
Controversy continues regarding the use of albumin in critically ill patients. According to a report from 15 academic health centers, albumin was prescribed to reach a defined end point in most of the cases. Only one adverse event was reported in the 969 forms evaluated. Inappropriate indications for albumin accounted for 62% of total costs noted in the report. The study concluded that institutions must define and implement guidelines that will focus on a more cost-efficient use of albumin.
In 1998 the Cochrane Injuries Group analyzed 30 studies involving more than 1400 patients. It found an excess mortality in patients treated with albumin compared with crystalloids. The indications for albumin were hypovolemia, burn injury, and hypoalbuminemia. In the United States, approximately 26% of albumin is given to treat acute hypovolemia, and less than 1% reportedly is used to correct low serum albumin. Limitations of meta-analyses that use mortality as an end point for this controversy have been reviewed extensively. Others have reexamined albumin use in critically ill patients. A meta-analysis of randomized controlled trials found no effect of albumin on mortality. An investigation of spontaneous serious adverse event reports showed an incidence of 1.29 such events/10 doses of albumin. Two additional reviews of albumin use in critically ill patients found pulmonary edema, mortality, and length of stay to be unaffected by fluid choice. In 2000, the Cochrane Database Systematic Reviews presented studies of albumin in critically ill patients for a variety of indications. No advantage was found for albumin over other colloids or crystalloids in these analyses. In response to the 1998 Cochrane Review, the Food and Drug Administration (FDA) cautioned the entire medical community to consider carefully the meta-analysis findings and adopt prescribing patterns that adhere to accepted guidelines.
Neurosurgical intensive care patients have not been represented adequately in these analyses. The meta-analysis findings from patients with burns, hypoalbuminemia, or hypovolemia would not apply to indications for use in neurosurgery. Aggressive fluid protocols commonly are implemented to prevent secondary ischemia after subarachnoid hemorrhage or severe traumatic brain injury. Albumin is often a component of these regimens, which are designed to maximize hemodynamics and maintain cerebral perfusion pressure (CPP). There is no evidence that albumin is superior to crystalloids for hypervolemic therapies in patients treated by neurosurgeons. The University HealthSystem Consortium, a clinical alliance of 87 academic health centers that publishes evidenced-based guidelines, does not support albumin for these indications. Nevertheless, this organization acknowledges that nonrandomized trials have suggested benefits for colloids, such as albumin, in these circumstances.
Controversy regarding the mortality associated with albumin, together with the limited literature addressing albumin use for neurosurgery indications, prompted our investigation. We sought to determine the pattern of albumin prescribing and gather preliminary evidence of the extent to which albumin is used by neurosurgeons.