Comparison of intravenous albumin and transfer of fresh embryos with cryopreservation of all embryos for subsequent transfer in prevention of ovarian hyperstimulation syndrome. Albumin treatment following major surgery. I. Effects on plasma oncotic pressure, renal function and peripheral oedema. Randomized trial of volume expansion with albumin or saline in children with severe malaria: preliminary evidence of albumin benefit. The value of an albumin-based intravascular volume replacement strategy in elderly patients undergoing major abdominal surgery. Albumin treatment following major surgery. II. Effects on postoperative lung function and circulatory adaptation. Therapeutic influence of 20 % albumin versus 6% hydroxyethylstarch on extravascular lung water in septic patients: a randomized controlled trial. Short-term effectiveness of different volume replacement therapies in postoperative hypovolaemic patients. Treatment of venous leg ulcers with cryopreserved cultured allogeneic keratinocytes: a prospective open controlled study. Distribution of normal saline and 5% albumin infusions in cardiac surgical patients.
To compare the efficacy of administration i.v. albumin to prevent severe ovarian hyperstimulation syndrome (OHSS) in patients undergoing ovarian stimulation for IVF with a standard policy of cryopreserving all embryos and to assess the impact of the two methods of treatment on pregnancy rates (PRs).
                Prospective randomized study.
                A tertiary referral center for assisted conception.
                Twenty-six patients undergoing IVF treatment cycles who were considered to be at high risk of developing severe OHSS on the basis of their serum E2 concentrations on the day of hCG administration and the number of oocytes collected.
                In group 1 (n = 13) all the generated embryos were cryopreserved to be transferred subsequently in hormonally manipulated cycles. In group 2 (n = 13) patients received IV infusions of albumin on the day of oocyte retrieval and 5 days later. Patients in group 2 had transfers of fresh embryos.
                The total dosage of hMG used, total number of follicles developed, number of follicles > 14 mm in diameter, serum E2 concentrations and endometrial thickness on day of hCG administration, number of oocytes retrieved, number and quality of embryos generated, PRs per cycle commenced, and onset and degree of any OHSS developed.
                There were no significant differences in the above parameters between the two groups, except for PRs that were significantly higher in patients who had all embryos cryopreserved (38.6% versus 0%).
                The policy of cryopreserving all generated embryos appears as effective as the administration of i.v. albumin in preventing OHSS in high-risk patients and produces significantly higher PRs. The effect of a 20% albumin solution on plasma oncotic pressure, renal function and peripheral oedema was investigated in 30 adult patients undergoing elective major abdominal surgery. Half of them received an average of 173 g of albumin between the end of the operation and the 5th postoperative day, in accordance with a standardized scheme. Otherwise the same schedules for fluid therapy and blood replacement were followed in all patients. Postoperatively, serum albumin and plasma oncotic pressure were fairly normal in the albumin group, but decreased by 28% and 24% in the control group. The difference between the groups was statistically significant during the first week, but disappeared during the second week. Arm and thigh circumferences increased postoperatively to a similar extent in both groups. There were no apparent differences in circulatory variables, alveolo-arterial oxygen tension difference, incidence of wound infection or postoperative restoration of intestinal activity between the groups. Although renal and thromboembolic complications occurred only in the control group, the material is too small to permit any conclusions to be drawn from the possible difference in renal function and morbidity between the groups. The limited availability and high cost of albumin require strict indications for its use. Our results so far have failed to justify routine administration of concentrated albumin postoperatively. Metabolic acidosis is the best predictor of death in children with severe falciparum malaria; however, its treatment presents a therapeutic dilemma, because acidosis and hypovolemia may coexist with coma, which can be associated with elevated intracranial pressure. We postulated that volume resuscitation with albumin might correct acidosis and hypovolemia with a lower risk of precipitating cerebral edema than crystalloid. In an open-label, randomized, controlled trial, we compared the safety of resuscitation with albumin to saline in Kenyan children with severe malaria.
                We randomly assigned children with severe malaria and metabolic acidosis (base deficit, >8 mmol/L) to receive fluid resuscitation with either 4.5% albumin or normal saline. A control (maintenance only) group was only included for patients with a base deficit of <15 mmol/L. The primary outcome measure was the percentage reduction in base deficit at 8 h. Secondary end points included death, the requirement for rescue therapies, and neurological sequelae in survivors.
                Of 150 children recruited for the trial, 61 received saline, 56 received albumin, and 33 served as control subjects. There was no significant difference in the resolution of acidosis between the groups; however, the mortality rate was significantly lower among patients who received albumin (3.6% [2 of 56 patients]) than among those who received saline (18% [11 of 61]; relative risk, 5.5; 95% confidence interval, 1.2-24.8; P=.013).
                In high-risk children with severe malaria and acidosis, fluid resuscitation with albumin may reduce mortality. Our study design did not enable us to determine whether saline administration is preferable to fluid restriction or whether saline administration is actually hazardous. Further studies are needed to confirm our findings before definitive treatment recommendations can be made. The value of human albumin (HA) for treating hypovolemia is controversial. Less expensive alternatives such as hydroxyethyl starch (HES) are sometimes refused because of unwanted side effects. We prospectively randomized 50 patients older than 70 years old undergoing major abdominal surgery to receive either 5% HA (n = 25) or a third generation HES preparation (6% HES 130/0.4; n = 25) when mean arterial blood pressure was <60 mm Hg and central venous pressure was <10 mm Hg. Hemodynamics, inflammation (interleukin-6), endothelial activation-integrity (adhesion molecules), coagulation (thrombelastography), and renal function (including kidney-specific proteins) were monitored after the induction of anesthesia, after surgery, 5 h in the intensive care unit, and on the first postoperative day. HA patients received 3960 +/- 590 mL of HA and 5070 +/- 1030 mL of Ringer's lactate solution, and HES patients received 3500 +/- 530 mL of HES and 4550 +/- 880 mL of Ringer's lactate solution. Total protein remained normal only in the HA-treated patients. No significant differences (P > 0.1) between the groups were seen with regard to hemodynamics, coagulation, and kidney function. Plasma levels of interleukin-6 and soluble adhesion molecules were significantly (P < 0.05) higher in the HA- than in the HES-treated patients. We conclude that HA in elderly patients undergoing major abdominal surgery can easily be replaced by a modern HES preparation. Because of the decreased inflammatory response and endothelial activation-injury, HES 130/0.4 seems to be the more appropriate fluid strategy for these patients. The effects of i.v. infusion of 5% albumin and balanced salt solutions were investigated in a prospective study on 18 patients subjected to reconstruction of the abdominal aorta. The same schedules for blood replacement and intraoperative fluid therapy were followed for all patients. Postoperatively, the amounts of fluid administered were adjusted with the aim of keeping the mean pulmonary arterial occlusion pressure (MPAOP) close to the preoperative level. Immediately after operation, there was a decrease in cardiac filling pressures, indicating a blood volume deficit, in both groups. Less fluid was needed for adequate haemodynamic restitution in the albumin group. Postoperatively, the mean plasma oncotic pressure (POP) in the albumin-treated patients remained steady at 2.4-2.5 kPa (86-88% of preoperative value). In the control group, POP fell to a mean minimum of 1.8 kPa (64% of preoperative value) 8 h after operation. The difference between POP and MPAOP decreased significantly in both groups, but the difference between the groups was not significant at any time. There was no significant correlation between venous admixture, on the one hand, and POP, MPAOP, POP-MPAOP difference, total sodium intake or net supply of non-colloid fluids, on the other. No clinically important differences in haemodynamic or lung function variables were found between the groups. Recent studies demonstrated that extravascular lung water (EVLW) is a reliable and independent marker for outcome. The primary therapeutically goal in critically ill patients is to resuscitate and retain adequate organ perfusion by fluid administration, where is necessary to achieve adequate intravascular filling, but avoid initiation of pulmonary edema.
                Patients with severe sepsis were randomly allocated to a group treated with 20% Albumin 100 ml every 12 hours (ALB; n = 30) or with 6% hydroxyethylstarch 130/0, 4 250 ml every 6 hours (HES; n = 26). Both treatments were completed by crystalloids or norephinephrin as necessary. We analyzed amount of developed EVLW, and relation with mortality, PaO2/FiO2 and alveolo-arterial oxygen difference.
                We observed significantly greater decrease of EVLW when compared with baseline during whole monitored period of 72 hours in ALB group in contrast to HES patients (p < 0.05). Despite no significant changes of EVLW in HES group, we noted improve of PaO2/FiO2 and AaDO2 in both groups. We did not observed significant difference in mortality.
                The present study results show can summarize that albumin reduces in a higher amount and earlier the extravascular lung water than HES, but this reduction was not associated with improvement of oxygenation functions, which was better in HES group. To examine the kinetics of volume loading with crystalloid and colloid infusions in critically ill patients after major surgery, using the pulse contour cardiac output (PiCCO) monitoring technique.
                This prospective, randomized, multicentre study of 11 ICUs involved 200 mixed postoperative hypovolaemic patients (50 patients per group) in Hungary. Patients received 10 ml kg of lactated Ringer's solution, succinylated gelatin 4% w/v, 130/0.4 hydroxyethyl starch 6% w/v (HES) or human albumin 5% w/v over 30 min. A complete haemodynamic profile was obtained at 30, 45, 60, 90 and 120 min after baseline. The peak haemodynamic effects, the 120 min changes compared with baseline, the area under the curve (AUC) for the haemodynamic parameters over 120 min and the haemodilution effect of the solutions were analysed. The primary outcome was to compare the AUCs and the secondary outcome was to evaluate the haemodynamic changes at 120 min.
                There were significant differences in the AUCs of the haemodynamic parameters between colloids and lactated Ringer's solution in the cardiac index and global end-diastolic volume index (GEDVI); human albumin vs. lactated Ringer's solution in stroke volume variation (SVV); and succinylated gelatin, HES vs. lactated Ringer's solution in the oxygen delivery index (DO2I). Colloid infusions (mainly HES and human albumin) at 120 min caused significant changes in central venous pressure, cardiac index, GEDVI, SVV, DO2I and central venous oxygen saturation compared with baseline. The haemodilution effect was significantly greater in colloids vs. lactated Ringer's solution.
                In postoperative hypovolaemic patients, lactated Ringer's solution can significantly improve haemodynamics at the end of volume loading, but this effect completely disappears at 120 min. Ten millilitres per kilogram of colloid bolus (especially HES) improved the haemodynamics at 120 min; however, this was by only 5-25% compared with baseline. The colloids caused significantly larger AUCs than lactated Ringer's solution, but only in the cardiac index, GEDVI and DO2I, plus human albumin in the SVV. Twenty-seven patients with chronic venous leg ulcers were assigned to two treatment groups. Fifteen were treated with cryopreserved cultured allogeneic keratinocyte sheets and compression bandages and 12 with compression only. The observation time was 8 weeks and the keratinocyte grafting procedure was performed once weekly. The mean reduction of the initial wound area was 35% in the treatment group and 14% in the control group. This difference was not significant. The poor effect on wound healing given by the cryopreserved allogeneic keratinocyte sheets contrasts with our earlier experience using fresh keratinocyte sheets. We believe that this is due to a weakened condition of the cryostored cells, as we have shown a loss in protein synthesis capacity of at least 50%. To determine the relative distribution of fluid within the extracellular fluid volume (ECFV) and the effect on oxygen delivery after infusing either normal saline or 5% albumin in cardiac surgical patients.
                Prospective, randomized, unblinded, interventional study.
                Cardiac surgical intensive care unit in a 450-bed teaching hospital.
                Postoperative cardiac surgical patients (n = 40).
                Infusion of either normal saline or 5% albumin to a hemodynamic end point determined by the patient's clinician.
                Plasma volume (PV), ECFV, cardiac index, and arterial oxygen content were measured immediately before (baseline) and after each fluid infusion. PV and ECFV were measured by dilution of (131)I-albumin and [(35)S]sodium sulfate, respectively. Interstitial fluid volume (ISFV) was calculated as ECFV - PV. Baseline values for PV, ISFV, ECFV, and oxygen delivery index did not differ between treatment groups. Infusion of normal saline and 5% albumin increased PV by 9 +/- 23% and 52 +/- 84% of the volume infused, respectively (p <.05), whereas there was no significant difference between saline and albumin in the change in ISFV per volume infused. Only 5% albumin significantly increased cardiac index, although oxygen delivery did not change significantly after either infusion.
                In postoperative cardiac surgical patients, infusion of 5% albumin is approximately five times as efficient as a PV expander but has comparable effects on changes in ISFV and oxygen delivery relative to normal saline.
This updated of the review (D'Angelo 2002) has showed that there is insufficient evidence to support routine cryopreservation and insufficient evidence for the relative merits of intra-venous albumin versus cryopreservation.