Impact of Albumin on Coagulation Competence and Hemorrhage During Major Surgery

Abstract

For patients exposed to a massive blood loss during surgery, maintained coagulation competence is important. It is less obvious whether coagulation competence influences bleeding during elective surgery where patients are exposed to infusion of a crystalloid or a colloid.This randomized controlled trial evaluates whether administration of 5% human albumin (HA) or lactated Ringer solution (LR) affects coagulation competence and in turn blood loss during cystectomy due to bladder cancer.Forty patients undergoing radical cystectomy were included to receive either 5% HA (n = 20) or LR (n = 20). Nineteen patients were analyzed in the HA group and 20 patients in the lactated Ringer group.Blinded determination of the blood loss was similar in the 2 groups of patients: 1658 (800–3300) mL with the use of HA and 1472 (700–4330) mL in the lactated Ringer group (P = 0.45). Yet, by thrombelastography (TEG) evaluated coagulation competence, albumin affected clot growth (TEG-angle 69 ± 5 vs 74° ± 3°, P < 0.01) and strength (TEG-MA: 59 ± 6 vs 67 ± 6 mm, P < 0.001) more than LR. Furthermore, by multivariate linear regression analyses reduced TEG-MA was independently associated with the blood loss (P = 0.042) while administration of albumin was related to the changes in TEG-MA (P = 0.029), aPPT (P < 0.022), and INR (P < 0.033).This randomized controlled trial demonstrates that administration of HA does not affect the blood loss as compared to infusion of LR. Also the use of HA did not affect the need for blood transfusion, the incidence of postoperative complications, or the hospital in-stay. Yet, albumin decreases coagulation competence during major surgery and the blood loss is related to TEG-MA rather than to plasma coagulation variables.

Choice of fluid type: physiological concepts and perioperative indications

“…Albumin 5% was compared to Ringer's lactate in radical cystectomy and to HES 130/0.4 during liver transplantations. 30,50 Albumin did not lead to altered outcome in terms of blood loss, AKI, or LOHS compared to Ringer's lactate in either study. 30,50 In the study focusing on renal function during liver transplantation, one out of 20 patients in both HES and albumin groups required renal replacement therapy.…”

“…48 However, the same authors could not repeat these findings in two comparative studies in a similar population when comparing Dextran 70 or albumin 5% with Ringer's lactate. 49,50 In conclusion, the majority of studies do not show a difference in blood loss between fluid types. These data should be viewed in light of different dosing strategies and populations amongst studies.…”

Hyperthermic intraperitoneal chemotherapy enhances blood coagulation perioperatively evaluated by thromboelastography: a pilot study

“…On the other hand, extreme dilution with albumin is associated with coagulopathy in TEG [33]. In vivo, the administration of albumin during major surgery had only a minor effect on TEG MA and blood loss and, importantly, no effect on TEG R time [34].…”

Changing practices of fluid therapy

“…This trend may even have accelerated further as a response to another recent study, also from Denmark, that showed a larger surgical hemorrhage when HES is used . By contrast, albumin does not seem to cause a similar increase in surgical hemorrhage, nor does it impair kidney function in septic patients …”