Impact of Albumin on Coagulation Competence and Hemorrhage During Major Surgery: A Randomized Controlled Trial

Kirsten C Rasmussen, Michael Højskov, Pär I Johansson, Irina Kridina, Thomas Kistorp, Lisbeth Salling, Henning B Nielsen, Birgitte Ruhnau, Tom Pedersen, Niels H Secher, Kirsten C Rasmussen, Michael Højskov, Pär I Johansson, Irina Kridina, Thomas Kistorp, Lisbeth Salling, Henning B Nielsen, Birgitte Ruhnau, Tom Pedersen, Niels H Secher

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.

Trial registration: ClinicalTrials.gov NCT02270723.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

FIGURE 1
FIGURE 1
Consort study flow diagram.
FIGURE 2
FIGURE 2
Correlation between TEG-MA and blood loss. Change in plasma TEG-MA from start (T1) to end of anesthesia (T3) in patients receiving lactated Ringer solution (▴) or albumin (•), r = −0.36 (95% CI −0.62 to −0.10), P = 0.02 Regression lines shown with 95% confidence interval. CI = confidence interval, TEG-MA = thrombelastography maximal amplitude.

References

    1. Zaar M, Lauritzen B, Secher NH, et al. Initial administration of hydroxyethyl starch vs. lactated Ringer after liver trauma in the pig. Br J Anaesth 2009; 102:221–226.
    1. Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets – a review of the current literature. Tranfusion 2010; 50:701–710.
    1. Gruen RL, Brohi K, Schreiber M, et al. Hemorrhage control in severely injured patients. Lancet 2012; 380:1099–1108.
    1. Lunde J, Stensballe J, Wikkelsø A, et al. Fibrinogen concentrate for bleeding – a systematic review. Acta Anaesthesiol Scand 2014; 58:1061–1074.
    1. Rasmussen KC, Johansson PI, Hoejskov M, et al. Hydroxyethyl starch reduces coagulation competence and increase blood loss during major surgery. Results from a randomized controlled trial. Ann Surg 2014; 2:249–254.
    1. Rasmussen KC, Hoejskov M, Johansson PI, et al. Coagulation competence for predicting perioperative haemorrhage in patients treated with lactated Ringer's vs Dextran – a randomized controlled trial. BMC Anesthesiol 2015; 15:178.
    1. Jacob M, Fellahi J, Chappell D, et al. The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis. Crit Care 2014; 18:656.
    1. Russell JA, Navickis RJ, Wilkes MM. Albumin versus crystalloid for pump priming in cardiac surgery: meta-analysis of controlled trials. J Cardiothorac Vasc Anesth 2004; 18:429–437.
    1. Adrian K, Mellgren K, Skogby M, et al. The effect of albumin priming solution on platelet activation during experimental long-term perfusion. Perfusion 1998; 13:187–191.
    1. Navickis RJ, Haynes GR, Wilkes MM. Effect of hydroxyethyl starch on bleeding after cardiopulmonary bypass: a meta-analysis of randomized trials. J Thorac Cardiovasc Surg 2012; 144:223–230.
    1. Skhirtladze K, Base EM, Lassnigg A, et al. Comparison of the effects of albumin 5%, hydroxyethyl starch 130/0.4 6%, and Ringer's lactate on blood loss and coagulation after cardiac surgery. Br J Anaesth 2013; 112:255–264.
    1. ICH Steering Committee. International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use: ICH Harmonised Tripartite Guideline for Good Clinical Practice. 3rd edLondon, UK: Brookwood Med Pub; 1998.
    1. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:299S–339S.
    1. de Vaal JB, de Wilde RB, van den Berg PC, et al. Less invasive determination of cardiac output from the arterial pressure by aortic diameter-calibrated pulse contour. Br J Anaesth 2005; 95:326–331.
    1. Bundgaard-Nielsen M, Holte K, Secher NH, et al. Monitoring of intraoperative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 2007; 51:331–340.
    1. Johansson PI, Svendsen MS, Salado J, et al. Investigation of the thrombin-generating capacity, evaluated by thrombogram and clot formation evaluated by thrombelastography of platelets stored in the blood bank for up to 7 days. Vox Sang 2008; 94:113–118.
    1. Niemi TT, Miyashita R, Yamakage M. Colloid solutions: a clinical update. J Anesth 2010; 24:913–925.
    1. The Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998; 317:235–240.
    1. Arunachalam L, MacFie J. Colloid versus crystalloid fluid therapy in surgical patients. BJS 2015; 102:145–147.
    1. Finfer S, Bellomo R, Boyce N, et al. SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247–2256.
    1. Ågren A, Wikman AT, Holmström M, et al. Thromboelastography (TEG®) compared to conventional coagulation tests in surgical patients – a laboratory evaluation. Scand J Clin Lab Invest 2013; 73:214–220.
    1. Pekelharing J, Furck A, Banya W, et al. Comparison between thromboelastography and conventional coagulation tests after cardiopulmonary bypass surgery in the paediatric intensive care unit. Int J Lab Hematol 2014; 36:465–471.
    1. Holcomb JB, Minei KM, Scerbo ML, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg 2012; 256:476–486.
    1. Bundgaard-Nielsen M, Secher NH, Kehlet H. ‘Liberal‘ vs. ‘restrictive‘ intraoperative fluid therapy: a critical assessment of the evidence. Acta Anaesthesiol Scand 2009; 53:843–851.
    1. Corcoran T, Rhodes JE, Clarke S, et al. Intraoperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 2012; 114:640–651.
    1. Matzen S, Perko G, Groth S, et al. Blood volume distribution during head-up tilt induced central hypovolaemia in man. Clin Physiol 1991; 1:411–422.
    1. Bundgaard-Nielsen M, Jørgensen CC, Secher NH, et al. Functional intravascular volume deficit in patients before surgery. Acta Anaesthesiol Scand 2010; 54:464–469.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する