Meta Analysis
Albumin administration for fluid resuscitation in burn patients: A systematic review and meta-analysis.
This review may be edited
Summary
Posted By: Gordon S. Doig
E-Mail: gdoig@med.usyd.edu.au
Posted Date: 7 Oct 2016
Title: Albumin administration for fluid resuscitation in burn patients: A systematic review and meta-analysis.
Authors: Eljaiek R, Heylbroeck C, and Dubois MJ.
Reference: Burns. 2016 Sep 6. pii: S0305-4179(16)30269-8.
Link: Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract: OBJECTIVE: The objective was to systematically review the literature summarizing the effect on mortality of albumin compared to non-albumin solutions during the fluid resuscitation phase of burn injured patients.
DATA SOURCES: We searched MEDLINE, EMBASE and CENTRAL and the content of two leading journals in burn care, Burns and Journal of Burn Care and Research.
STUDY SELECTION: Two reviewers independently selected randomized controlled trials comparing albumin vs. non-albumin solutions for the acute resuscitation of patients with >20% body surface area involvement. DATA EXTRACTION: Reviewers abstracted data independently and assessed methodological quality of the included trials using predefined criteria.
DATA SYNTHESIS: A random effects model was used to assess mortality. We identified 164 trials of which, 4 trials involving 140 patients met our inclusion criteria. Overall, the methodological quality of the included trials was fair. We did not find a significant benefit of albumin solutions as resuscitation fluid on mortality in burn patients (relative risk (RR) 1.6; 95% confidence interval (CI), 0.63-4.08). Total volume of fluid infusion during the phase of resuscitation was lower in patients receiving albumin containing solution -1.00ml/kg/%TBSA (total body surface area) (95% CI, -1.42 to -0.58).
CONCLUSION: The pooled estimate demonstrated a neutral effect on mortality in burn patients resuscitated acutely with albumin solutions. Due to limited evidence and uncertainty, an adequately powered, high quality trial could be required to assess the impact of albumin solutions on mortality in burn patients.
 
Are the Results Valid?
1. Did the overview address a focused clinical question?
Yes. The authors hypothesized that the systematic use of albumin in the acute resuscitation of burn injured patients would not be beneficial. Trials of adults and children were included in the ITT analysis, and albumin was compared to any crystaloid solution (balanced, hypertonic). Subgroup analyses addressed effects in adults only and balanced electrolytes only.
2. Were the criteria used to select articles for inclusion appropriate?
Yes. Two reviewers (RE, MJD) independently screened abstract citations, retrieved articles and assessed trials for study inclusion. Parallel-group RCTs that compared albumin to non-albumin solutions in the resuscitation of burn patients (> 20% BSA) within 24 h of injury and admitted to a Burn Intensive Care Unit were included.
3. Is it unlikely that important, relevant studies were missed?
Yes. The authors searched searched MEDLINE, EMBASE and CENTRAL using the OVID search engine.
4. Was the validity of the included studies appraised?
Yes. Table 2 reports key methodological features. No pseudo-randomised trials were included in the MA.
5. Were assessments of studies reproducible?
Yes. Two authors conducted study identification and data abstraction.
6. Were the results similar from study to study?
Heterogeneity was medium (I2 = 41%) to low (I2=0%)
What are the Results?
1. What are the overall results of the overview?
The autors used a random effects model for their primary analysis of mortality. When outcome events are sparse, the most commonly used random effects model is known to be biased. This reviewer (GSD) repeated the analysis using the method of Peto, which is not biased in the presence of sparse outcomes.
2. How precise were the results?
Primary outcome: Mortality
  • There was a trend towards an increase in mortality associated with the use of Albumin (OR 1.08, 95% confidence interval 0.93 to 4.61, P=0.07, I2=35.6%) in the intention to treat analysis that included all identified trials.
    A priori defined subgroup analyses
  • When the study by Recinos was excluded because it enrolled children, meta-analysis of the remaining three studies conducted in adults demonstrates a significant increase in mortality attributable to albumin use (OR 3.18, 95% confidence interval 1.15 to 8.75, P= 0.03, I2=29.2%).
  • When the study by Jeleko was excluded because it did not compare albumin to balanced crystalloid, mortality was also significantly increased in patients receiving albumin (Figure 3, OR 2.58, 95% confidence interval 1.05 to 6.33, P=0.04, I2=43.1%).
  • Will the Results Help Me In Caring For My Patients?
    1. Can the results be applied to my patient care
    Yes, the interventions evaluated are clinically relevant and the patients included in review are likely reasonably representative.
    2. Were all clinically important outcomes considered?
    Mortality and volume of fluid was considered.
    Graft failure, infections, costs and quality of life should also be considered. However, in the context of increased mortality, a 'trade off' if other outcomes were improved would be complex.
    3. Are the benefits worth the harms and costs?
    With a strong suggestion of excess harm, more evidence is required to support the continued use of albumin in this patient population.

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