Elsevier

Journal of Critical Care

Volume 35, October 2016, Pages 161-167
Journal of Critical Care

Sepsis/Infection
Fluid management in sepsis: The potential beneficial effects of albumin

https://doi.org/10.1016/j.jcrc.2016.04.019Get rights and content

Abstract

Fluid administration is a key intervention in hemodynamic resuscitation. Timely expansion (or restoration) of plasma volume may prevent tissue hypoxia and help to preserve organ function. In septic shock in particular, delaying fluid resuscitation may be associated with mitochondrial dysfunction and may promote inflammation. Ideally, infused fluids should remain in the plasma for a prolonged period. Colloids remain in the intravascular space for longer periods than do crystalloids, although their hemodynamic effect is affected by the usual metabolism of colloid substances; leakage through the endothelium in conditions with increased permeability, such as sepsis; and/or external losses, such as with hemorrhage and burns. Albumin has pleiotropic physiological activities including antioxidant effects and positive effects on vessel wall integrity. Its administration facilitates achievement of a negative fluid balance in hypoalbuminemia and in conditions associated with edema. Fluid resuscitation with human albumin is less likely to cause nephrotoxicity than with artificial colloids, and albumin infusion has the potential to preserve renal function in critically ill patients. These properties may be of clinical relevance in circulatory shock, capillary leak, liver cirrhosis, and de-escalation after volume resuscitation. Sepsis is a candidate condition in which human albumin infusion to preserve renal function should be substantiated.

Section snippets

Impact of plasma volume expansion on microvascular perfusion

Circulatory failure or shock is associated with a high risk of death and characterized by hemodynamic alterations that result in impaired tissue perfusion [1], [2]. Fluid resuscitation is one of the most frequent interventions used at the bedside to improve tissue perfusion, especially in septic shock. In experimental models of sepsis, generous fluid administration is associated with improved survival [3], [4]. Fluids should also be given in a timely fashion. Compared to early administration,

Potential beneficial effects of albumin in patients

Since 2000, several large randomized controlled trials (RCTs) have been performed to clarify the efficacy and safety of volume resuscitation in critically ill patients. The results of these studies have encouraged new thinking about the role of artificial colloids and paved the way for the development of lower risk crystalloids. In contrast to results of small trials using nonvalidated surrogate markers, several large RCTs have confirmed an increased need for renal replacement therapy and a

Conclusions and future directions

The plasma-expanding effects of crystalloids and colloids are decreased in conditions of increased permeability, but the extent and duration of plasma expansion remain higher with colloids than with crystalloids. Both types of fluid can increase microvascular perfusion, but there is marked individual variability in this effect. The impact of the type of fluid on microvascular perfusion and function needs to be better defined.

Albumin has pleiotropic physiological activities, including

Acknowledgments

This review is based on the lectures presented at the satellite symposium organized by Grifols, manufacturer of albumin, held on February 6, 2015, in Barcelona (Spain), in the context of the 20th International Symposium on Infections in the Critically Ill Patient.

Jordi Bozzo, PhD, CMPP, and Eva Medina (Grifols) are acknowledged for their editorial assistance in the preparation of the manuscript.

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    Conflicts of interest: JLV declares no conflict of interest regarding this manuscript. DDB declares receiving honoraria as a speaker for Grifols. CW declares receiving honoraria as a speaker for Kedrion, CSL Behring, Baxter, and Grifols and as a consultant for CSL Behring and Grifols.

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