Albumin Resuscitation for Traumatic Brain Injury: Is Intracranial Hypertension the Cause of Increased Mortality?

Abstract

Mortality is higher in patients with traumatic brain injury (TBI) resuscitated with albumin compared with saline, but the mechanism for increased mortality is unknown. In patients from the Saline vs. Albumin Fluid Evaluation (SAFE) study with TBI who underwent intracranial pressure (ICP) monitoring, interventional data were collected from randomization to day 14 to determine changes in ICP (primary outcome) and in therapies used to treat increased ICP. Pattern mixture modelling, designed to address informative dropouts, was used to compare temporal changes between the albumin and saline groups, and 321 patients were identified, of whom 164 (51.1%) received albumin and 157 (48.9%) received saline. There was a significant linear increase in mean ICP and significantly more deaths in the albumin group compared with saline when ICP monitoring was discontinued during the first week (1.30 -0.33 vs. -0.37 -0.36, p = 0.0006; and 34.4% vs. 17.4%; p = 0.006 respectively), but not when monitoring ceased during the second week (-0.08 -0.44 vs. -0.23 -0.38, p = 0.79; and 18.6% vs. 12.1%; p = 0.36 respectively). There were statistically significant differences in the mean total daily doses of morphine (-0.42 -0.07 vs. -0.66 -0.0, p = 0.0009), propofol (-0.45 -0.11 vs. -0.76 -0.11; p = 0.034) and norepinephrine (-0.50 -0.07 vs. -0.74 -0.07) and in temperature (0.03 -0.03 vs. 0.16 -0.03; p = 0.0014) between the albumin and saline groups when ICP monitoring ceased during the first week. The use of albumin for resuscitation in patients with severe TBI is associated with increased ICP during the first week. This is the most likely mechanism of increased mortality in these patients. Methods Study designThis study was an additional post-hoc analysis of a subgroup of patients with TBI who were randomized into a prospective, blinded

Prognostic significance of blood-brain barrier disruption in patients with severe nonpenetrating traumatic brain injury requiring decompressive craniectomy

“…A recent post hoc analysis of a multicenter study that compared use of albumin versus saline as a resuscitation fluid showed that use of intravenous albumin was associated with higher ICP within the first week of TBI and worse long-term outcomes. 7 The results of our study support a hypothesis that intravenous albumin can be especially harmful when used in patients who have sustained a particularly severe TBI and who are therefore more likely to have significant BBB disruption. Albumin is a relatively large molecule (molecular weight 69 kD), and if albumin can leak through a BBB disruption after severe TBI, other smaller, osmotically active molecules, such as gelatin, could potentially also leak across the BBB and possibly worsen cerebral edema in patients after severe TBI.…”

State-of-the-art fluid management in the operating room

“…A post hoc subset analysis of the SAFE study for patients with traumatic brain injury (n ¼ 460) revealed a lower mortality rate in patients treated with NS compared with albumin (33.2% vs. 20.4%) [65]. It is important to note that the albumin preparation used in the SAFE study, 4% Albumex ® (CSL, Melbourne), was relatively hypotonic (260 mOsmol/l), and this hypotonicity may have contributed to worse outcomes in the albumin group [66]. Otherwise, the use of balanced crystalloid solutions seems to be beneficial.…”

Людський Сироватковий Альбумін (Минуле Та Майбутнє)

“…Од-нако в исследовании SAFE [15] у больных с острой черепно-мозговой травмой, получавших 4% раствор ЧСА, исходы были хуже, чем у больных, получавших солевые растворы. Это связывали с тем, что гипоос-молярный (4%) раствор альбумина повышал интра-краниальное давление и отек головного мозга [25]. Вместе с тем применение 4% и 20% растворов ЧСА у 93 пострадавших с тяжелой черепно-мозговой трав-мой (шкала комы Глазго ≤ 8 баллов) при соблюдении нулевого или слабо отрицательного водного баланса обеспечивало низкую летальность у больных данной группы [26] и подтверждало необходимость исклю-чения из терапии гипоосмолярных растворов ЧСА.…”