Meta Analysis
Human albumin administration in critically ill
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This review may be
edited
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Summary
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Posted By: |
Gordon S. Doig |
E-Mail: |
Gordon.Doig@EvidenceBased.net
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Posted Date: |
March 6th, 2001 |
Title: |
Human albumin administration in critically ill |
Authors: |
Cochrane Injuries Group albumin Reviewers |
Reference: |
BMJ 1998;317:235-240 |
Link: |
Click here for a direct link to the paper. A password may be required for access to fulltext.
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Abstract: |
Objective: To quantify effect on mortality of
administering human albumin or plasma protein
fraction during management of critically ill
patients.
Design: Systematic review of randomised
controlled trials comparing administration of
albumin or plasma protein fraction with no
administration or with administration of crystalloid
solution in critically ill patients with hypovolaemia,
burns, or hypoalbuminaemia.
Subjects: 30 randomised controlled trials
including 1419 randomised patients.
Main outcome measure: Mortality from all causes
at end of follow up for each trial.
Results: For each patient category the risk of
death in the albumin treated group was higher
than in the comparison group. For hypovolaemia
the relative risk of death after albumin
administration was 1.46 (95% confidence interval
0.97 to 2.22), for burns the relative risk was 2.40
(1.11 to 5.19), and for hypoalbuminaemia it was
1.69 (1.07 to 2.67). Pooled relative risk of death
with albumin administration was 1.68 (1.26 to
2.23). Pooled difference in the risk of death with
albumin was 6% (95% confidence interval 3% to
9%) with a fixed effects model. These data
suggest that for every 17 critically ill patients
treated with albumin there is one additional death.
Conclusions: There is no evidence that albumin
administration reduces mortality in critically ill
patients with hypovolaemia, burns, or
hypoalbuminaemia and a strong suggestion that it
may increase mortality. These data suggest that
use of human albumin in critically ill patients
should be urgently reviewed and that it should not
be used outside the context of rigorously
conducted, randomised controlled trials. |
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Are the Results Valid?
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1.
Did the overview address a focused clinical question? |
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Unsure. The authors state their objective is to
'quantify effect on mortality of administering
human albumin or plasma protein fraction during
management of critically ill patients'.
'Management of critically ill patients' is an
extremely broad topic and the review would be
better served to address a more focused question.
For example management of hypoalbuminemia,
hypotension and burns may each be complex and
different enough to qualify as individual questions. |
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2.
Were the criteria used to select articles for inclusion appropriate? |
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Unsure. All randomized trials of 'albumin
supplementation in critically ill patients' were
included however the authors also included 'pseudo-randomized trials'. It is widely accepted that most pseudo-randomized trials fail to maintain allocation concealment. Proper mantenance of allocation concealment can reduce bias by up to 40%. Trials that supplemented albumin in TPN
were included along with trials that treated
albumin as a pure colloid. |
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3.
Is it unlikely that important, relevant studies were missed? |
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No. The literature search was very thorough and it
is doubtful that important trials were missed. |
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4.
Was the validity of the included studies appraised? |
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Unsure. Trials were graded for adequacy of
concealment of allocation. Trials were not graded
on any other methodologic criteria (e.g. blinding, presentation of complete follow-up and ITT results). |
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5.
Were assessments of studies reproducible? |
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Unsure. There is no report of agreement levels
(kappas) between reviewers on validity appraisal or
inclusion decisions. |
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6.
Were the results similar from study to study? |
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Yes. The chi-square for heterogeneity was
reported as being non-significant within groups
and overall. |
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What are the Results?
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1.
What are the overall results of the overview? |
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For burns and hypoalbuminemia, the 95% CI on
relative risk of increased mortality with albumin
was 1.11-5.19 and 1.07-2.67 respectively. When
the poor quality trials were removed, the authors
report that both CIs become non-significant
(0.69-8.79 and 0.92-3.18).
For hypovolemia, the increased risk of mortality
with albumin was non-significant regardless of
whether the poor quality trials were left in or
removed (0.97-2.22 with all trials and 0.80-2.40
with only high quality trials).
The authors report that the overall pooled risk is
significantly increased with all trials or with only
the high quality trials. Interpretation of this overall
pooled risk hinges on whether you believe
hypotension,burns and/or hypoalbumineamia are clinically similar
and thus can be pooled. |
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2.
How precise were the results? |
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The 95% CIs are discussed above. |
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Will the Results Help Me In Caring For My Patients?
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1.
Can the results be applied to my patient care |
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Unsure. If the results are interpreted within
indications (i.e. not pooling hypovol with hypoalb
and burns) the conclusions would be much more
robust.
Although this paper appears to provide compelling
evidence for increased risk being associated with
albumin usage, due to the combination of
clinically herterogeneous indications this conclusion may not be valid.
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2.
Were all clinically important outcomes considered? |
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Yes. Although it would be nice to see length of
stay and costs, these are very hard to include in a
meta-analysis. Mortality is probably the most
important outcome in each of the clinical
scenarios reviewed. |
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3.
Are the benefits worth the harms and costs? |
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Unsure at this point in time. |
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Human albumin administration in critically ill
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