20 percent albumin bests plasmalyte for reversing sepsis-induced hypotension in cirrhosis patients
Aizawl: A new article published in the Journal of Hepatology showed that in individuals with cirrhosis and sepsis-induced hypotension, 20% albumin improves hemodynamics and lactate clearance faster than plasmalyte. 28-day survival was similar in both the groups and patients on 20% albumin experienced more pulmonary complications.
It is uncertain which resuscitation fluid should be used in individuals with cirrhosis and sepsis-induced hypotension. In the FRISC research, 5% albumin outperformed normal saline. Rakhi Maiwall and colleagues undertook this study to assess the effectiveness and safety of 20% albumin, which has stronger oncotic characteristics, to plasmalyte in treating sepsis-induced hypotension.
For this research critically sick cirrhotic patients were randomly assigned to receive either plasmalyte (30 ml/kg over 3 hours; n = 50) or 20% albumin (0.5-1.0 g/kg over 3 hours; n = 50). The primary goal of the study was to achieve a mean arterial pressure (MAP) greater than 65 mmHg after 3 hours.
The key findings of this study were as follows:
1. The baseline parameters of the albumin and plasmalyte groups, as well as arterial lactate, MAP, and SOFA score, were equivalent.
2. The majority of patients (39%) were alcoholics with pneumonia (40% ).
3. In the intention-to-treat study, albumin outperformed plasmalyte in terms of meeting the main outcome.
4. Albumin was associated with a quicker fall in arterial lactate, a lower requirement for dialysis, and a longer delay to dialysis beginning (in hours).
5. However, the 28-day mortality rate was not different, and therapy had to be terminated in 11 (22%) of the albumin group due to side effects, but there were no discontinuations in the plasmalyte group.
In conclusion, this study indicated that albumin outperformed plasmalyte in terms of a quick improvement in microcirculation, lactate clearance, and shock reversal, but at the expense of a higher risk of pulmonary consequences. However, there were no differences in overall clinical outcomes improvement. Future RCTs should look at whether combining gradual albumin infusion with plasmalyte is a superior method.
Reference:
Maiwall, R., Kumar, A., Pasupuleti, S. S. R., Hidam, A. K., Tevethia, H., Kumar, G., Sahney, A., Mitra, L. G., & Sarin, S. K. (2022). A randomized-controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsis-induced hypotension [ALPS trial]. In Journal of Hepatology. Elsevier BV. https://doi.org/10.1016/j.jhep.2022.03.043
