Discussion
In this review, low volume resuscitation with hyperoncotic human albumin
and hypertonic saline in patients following revascularization cardiac
surgery was explored. In the literature currently available, the use of
hyperoncotic albumin for post-CABG resuscitation has been published on
more extensively when compared to HS, with the HERCULES trial being the
major randomized controlled trial in progress investigating the role of
HS in patients post-CABG [21]. The objectives of both bodies of
literature aim to delineate whether or not resuscitation with
concentrated albumin and saline improved hemodynamics more efficiently
than their isooncotic fluid counterparts [20, 21, 24]. In addition,
these analyses further attempted to identify whether resuscitation with
these alternative, concentrated intravenous fluids impacted overall
fluid balance [20, 21].
In total, the results from the available data did not consistently show
hyperoncotic colloid to be a more superior volume expander when compared
to crystalloid solutions in patients following cardiac revascularization
procedure [20, 24]. Moreover, the current evidence did not
demonstrate an appreciable difference in mortality in post-CABG patients
resuscitated with 20-25% human albumin when compared to crystalloid
fluid therapy [20, 24]. Similarly, while resuscitation with HS in
the critically ill has been shown to increase CO and MAP to a greater
extent compared to a similar volume of NS [74], this has yet to be
determined in patients following CABG-procedure [20, 21].
While the current evidence in support of using concentrated human
albumin and saline remains equivocal, the literature available for
interpretation has its limitations. First, the number of publications
studying the use of HS and concentrated albumin in post-CABG patients is
sparse, composed of small patient cohorts. Moreover, the available
studies included in this analysis used static hemodynamic parameters
(i.e CO, CI, CVP, Urine output and MAP) to quantify hemodynamic changes,
metrics known to be poor predictors of fluid responsiveness [60,
81]. Additionally, these studies did not comment on the type of fluid
patients were given pre-operatively, intra-operatively, or the type of
fluid used to prime the cardiopulmonary bypass circuit, which could have
impacted their overall results. Finally, while the 2019 Enhanced
Recovery after Cardiac Surgery guidelines recommends goal directed fluid
therapy (an algorithmic approach to resuscitation), no universal
protocol exists for post-operative resuscitation following
CABG-procedure [82]. Accordingly, the studies included in this
review had unique protocols to guide the administration of intravenous
therapy.
In lieu of the static hemodynamic markers used in the available studies,
future analyses could instead use functional dynamic measures of stroke
volume, such as pulse pressure variation, stroke volume variation, and
systolic pressure variation to more reliably quantify fluid
responsiveness [60, 81, 83]. In addition to this, echocardiography
could be used to guide clinical practice by evaluating biventricular
function and volume assessment, an imaging modality that would more
reliably quantify fluid responsiveness [84]. Finally, the passive
leg raise (PLR) could be of use to aid clinicians in determining the
need for FBT in future studies on HS and hyperoncotic albumin in
post-CABG patients [81, 85]. Future studies utilizing more accurate
measurements of volume status, fluid responsiveness and cardiac output
could therefore further determine the role of concentrated human albumin
and saline in patients following revascularization cardiac surgery,
through prospective randomized controlled trials.
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