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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