Use of albumin in intensive care unit patients--is continuous quality assessment necessary?

Key Controversies in Colloid and Crystalloid Fluid Utilization

Nearly 2 centuries have passed since the use of intravenous fluid became a foundational component of clinical practice. Despite a steady stream of published investigations on the topic, questions surrounding the choice, dose, timing, targets, and cost-effectiveness of various fluid options remain insufficiently answered. In recent years, 2 of the most debated topics reference the role of albumin in acute care and the safety of normal saline. Although albumin has a place in therapy for specific patient populations, its high cost relative to other fluids makes it a less desirable option for hospitals and health systems with escalating formulary scrutiny. Pharmacists bear responsibility for reconciling this disparity and supporting the rational use of albumin in acute care through a careful evaluation of recently published literature. In parallel, it has become clear that crystalloids should no longer be considered a homogenous class of fluids. The past reliance on normal saline has been questioned due to recent findings of renal dysfunction attributable to the solution's supraphysiologic chloride concentration. These safety concerns with 0.9% sodium chloride may result in a practice shift toward more routine use of "balanced crystalloids," such as lactated Ringer's or Plasma-Lyte, that mimic the composition of extracellular fluid. The purpose of this review is to summarize the evidence regarding these 2 important fluid controversies that are likely to affect hospital pharmacists in the coming decades - the evidence-based use of human albumin and the rising role of balanced salt solutions in clinical practice.

Use of albumin in three French university hospitals: is prescription monitoring still useful in 2004?

PURPOSE

Use of albumin (indications and quantities involved) has not been assessed in France since major changes occurred after the publication of Cochrane group meta-analysis. The objectives of this study were to measure the repartition of albumin indications in three French university hospitals in 2004 and to assess the feasibility and usefulness to implement a prescription-monitoring program.

METHODS

Exhaustive record of albumin prescription during 2 months in three French university hospitals of Marseille. Inclusion of all patients with a first prescription of albumin between 15 March 2004 and 15 May 2004. Indication, formulation and quantity prescribed were recorded for each prescription.

RESULTS

One hundred and eighty-seven patients received a total of 426 prescriptions for a total quantity of 21 094 g of albumin during the study. The first indications were hypoalbuminemia (33% of total quantity), plasmapheresis (30.2%) and ascites or hepatorenal syndrome (13.7%). Fifty per cent of total quantity was used by 14 patients (7.5% of included patients).

CONCLUSIONS

Most of albumin consumption in our study is concentrated on recognized indications or indications without alternative to albumin. The different levels of analysis (number of patient treated, number of prescription and quantities used) must be taken into account when analyzing medications such as albumin. Only a marginal proportion of consumption is expected to be saved with close monitoring of indications.

Evaluation of Serum Albumin Utilization in Inpatient at a Private Hospital in Bangkok

Serum albumin is widely used for the treatment of hypovolemia, shock, hyperbilirubinemia or acute liver failure. However, serum albumin itself may have a significant effect on the action, elimination or distribution of other medications in blood which may affect the outcome of the treatment. Besides, it is also expensive and, most important, can be a carrier for many life-threatening diseases such as AIDS. The objective of this study is to evaluate the serum albumin utilization in inpatient at a private hospital in Bangkok, Thailand. Descriptive, retrospective study was designed to monitor the 25% w/v serum albumin orders over a four-month period. The background information, doses and rational of serum albumin orders, other medication orders, side effects, the interaction between serum albumin and other medications, the laboratory results and also clinical outcome of the patients were recorded. From the medication orders of 74 inpatients, there were 104 orders of serum albumin for 9 indications. The most common indications were hypoalbuminemia (48%) and cirrhosis (9%). From the total number of serum albumin orders, there were only 67 orders (64.4%) prescribed with rational dose and duration under appropriate indications. Totally about 35.6% of serum albumin orders were prescribed with improper indications such as edema, anemia or coronary artery bypass grafting. Out of 35.6%, 14% of the orders were prescribed to contraindicated patients. No side effect of serum albumin infusion was found during this study. The result indicates the over-utilization of serum albumin and specific guideline for using this agent should be set in every hospital.

Evaluation of human albumin use in a university hospital in Belgium

In 1996-1997, a drug use evaluation (DUE) of human albumin was conducted in the Ghent University Hospital (Belgium) to determine the pattern and appropriateness of the albumin use. The DUE was followed by permanent review of the albumin consumption. This paper describes how the DUE was carried out and how the albumin use in our hospital changed over time.

METHOD

The study was based on criteria for indications and end of treatment, accepted by consensus of the physicians prescribing albumin. Albumin treatment episodes were classified as appropriate or inappropriate according to these criteria.

RESULTS

For 115 treatment episodes in 90 patients, the researchers found 21 (18.3%) deviations from the developed criteria. After analysis, half out of them were considered as minor. Most deviations involved starting treatment too early (n = 17). Follow-up results indicated that the overall consumption of albumin dropped by 50.1% from 1994 to 1999, while the consumption of colloid solutions during the same period remained stable.

CONCLUSION

A good compliance with internally developed criteria for indications and end of treatment with human albumin was observed. Discussion with the clinicians involved led to the development of stricter criteria and a continuous decrease in albumin consumption.