The document discusses the role of albumin in the pediatric intensive care unit. It summarizes the controversy around albumin administration based on conflicting results from meta-analyses in the late 1990s and 2000s. Specifically, the first meta-analysis in 1998 suggested albumin administration could be harmful, while the second in 2001 found it was safe but not beneficial, and the third in 2003 was in favor of clinical use. More recent large trials like SAFE from 2004 found albumin was as safe as saline for volume resuscitation in critically ill patients, though subgroups like severe sepsis and traumatic brain injury showed different outcomes. Maintaining normal albumin levels above 3 g/dL was found to be beneficial to organ function in Dubois
Three sentences:
The document summarizes evidence from studies comparing normal saline to balanced crystalloid solutions like Ringer's lactate for intravenous fluid therapy. Large randomized controlled trials found balanced crystalloids were associated with fewer kidney complications compared to normal saline, especially in critically ill patients. More recent studies found no significant differences in outcomes between fluid types when administered at different rates, suggesting volume may be a more important factor than specific fluid used.
This document discusses coagulopathies and bleeding disorders that are common in critical care patients. It covers the basics of coagulation testing and the mechanisms, diagnosis, and management of various coagulation disorders including disseminated intravascular coagulation (DIC), liver disease, thrombocytopenia, heparin-induced thrombocytopenia (HITT), thrombotic microangiopathies, and renal disease. Key points include diagnostic criteria for DIC and HITT, treatment guidelines for major bleeding and invasive procedures, and transfusion thresholds for platelets in different clinical contexts.
This document summarizes different intravenous (IV) fluid options used in intensive care, including crystalloids, colloids, and specific fluid products. Crystalloids like saline readily diffuse out of blood vessels, while colloids like albumin, hetastarch, and pentastarch remain in circulation longer due to their larger size. Albumin is the main protein in blood plasma and expands volume the least of colloids. Hetastarch is a synthetic starch that expands volume more than albumin but can cause coagulopathy in large doses. Pentastarch is a newer low-molecular-weight hetastarch derivative that may cause fewer side effects.
This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.
This document discusses fluid resuscitation in acute kidney injury (AKI). It notes that AKI is common in critically ill patients, especially those with septic shock. While early goal-directed therapy was previously recommended, large trials found no benefit over usual care. The document discusses assessing volume status and differentiating fluid responders from non-responders using techniques like passive leg raising. It recommends crystalloids over colloids for initial fluid resuscitation in AKI. Normal saline may remain a reasonable first-line crystalloid but balanced solutions have not been shown to cause harm. Fluid overload can worsen outcomes and should be avoided.
Guideline for blood transfusion in newborn (NNF)mandar haval
This document provides guidelines for blood transfusion in newborns. It discusses pre-transfusion testing including donor selection, blood typing, and leucodepletion. It recommends irradiated and CMV-negative blood for high-risk newborns. Indications for packed red blood cells, platelets, fresh frozen plasma, and granulocytes are outlined. Transfusion volumes and rates are specified. Complications of blood transfusion like infections and immunologic reactions are also mentioned.
This document discusses chronic kidney disease (CKD), anemia in CKD, and treatments for anemia in CKD. It defines CKD and its stages based on glomerular filtration rate and kidney damage. Anemia in CKD is defined based on hemoglobin levels. Causes of anemia in CKD include relative erythropoietin deficiency, iron deficiency, blood loss, shortened red blood cell lifespan, and the "uremic milieu." Iron therapy and erythropoiesis-stimulating agents (ESAs) are discussed as treatments for anemia in CKD, including criteria for starting therapy, drug options, dosing, monitoring, and dose adjustment.
High frequency oscillatory ventilation (HFOV) is a type of mechanical ventilation that uses a constant distending pressure (mean airway pressure [MAP]) with pressure variations oscillating around the MAP at very high rates (up to 900 cycles per minute). This creates small tidal volumes, often less than the dead space.
Three sentences:
The document summarizes evidence from studies comparing normal saline to balanced crystalloid solutions like Ringer's lactate for intravenous fluid therapy. Large randomized controlled trials found balanced crystalloids were associated with fewer kidney complications compared to normal saline, especially in critically ill patients. More recent studies found no significant differences in outcomes between fluid types when administered at different rates, suggesting volume may be a more important factor than specific fluid used.
This document discusses coagulopathies and bleeding disorders that are common in critical care patients. It covers the basics of coagulation testing and the mechanisms, diagnosis, and management of various coagulation disorders including disseminated intravascular coagulation (DIC), liver disease, thrombocytopenia, heparin-induced thrombocytopenia (HITT), thrombotic microangiopathies, and renal disease. Key points include diagnostic criteria for DIC and HITT, treatment guidelines for major bleeding and invasive procedures, and transfusion thresholds for platelets in different clinical contexts.
This document summarizes different intravenous (IV) fluid options used in intensive care, including crystalloids, colloids, and specific fluid products. Crystalloids like saline readily diffuse out of blood vessels, while colloids like albumin, hetastarch, and pentastarch remain in circulation longer due to their larger size. Albumin is the main protein in blood plasma and expands volume the least of colloids. Hetastarch is a synthetic starch that expands volume more than albumin but can cause coagulopathy in large doses. Pentastarch is a newer low-molecular-weight hetastarch derivative that may cause fewer side effects.
This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.
This document discusses fluid resuscitation in acute kidney injury (AKI). It notes that AKI is common in critically ill patients, especially those with septic shock. While early goal-directed therapy was previously recommended, large trials found no benefit over usual care. The document discusses assessing volume status and differentiating fluid responders from non-responders using techniques like passive leg raising. It recommends crystalloids over colloids for initial fluid resuscitation in AKI. Normal saline may remain a reasonable first-line crystalloid but balanced solutions have not been shown to cause harm. Fluid overload can worsen outcomes and should be avoided.
Guideline for blood transfusion in newborn (NNF)mandar haval
This document provides guidelines for blood transfusion in newborns. It discusses pre-transfusion testing including donor selection, blood typing, and leucodepletion. It recommends irradiated and CMV-negative blood for high-risk newborns. Indications for packed red blood cells, platelets, fresh frozen plasma, and granulocytes are outlined. Transfusion volumes and rates are specified. Complications of blood transfusion like infections and immunologic reactions are also mentioned.
This document discusses chronic kidney disease (CKD), anemia in CKD, and treatments for anemia in CKD. It defines CKD and its stages based on glomerular filtration rate and kidney damage. Anemia in CKD is defined based on hemoglobin levels. Causes of anemia in CKD include relative erythropoietin deficiency, iron deficiency, blood loss, shortened red blood cell lifespan, and the "uremic milieu." Iron therapy and erythropoiesis-stimulating agents (ESAs) are discussed as treatments for anemia in CKD, including criteria for starting therapy, drug options, dosing, monitoring, and dose adjustment.
High frequency oscillatory ventilation (HFOV) is a type of mechanical ventilation that uses a constant distending pressure (mean airway pressure [MAP]) with pressure variations oscillating around the MAP at very high rates (up to 900 cycles per minute). This creates small tidal volumes, often less than the dead space.
This document discusses acid-base disorders and interpretation of arterial blood gases (ABGs) and spirometry. It provides:
1. An overview of acid-base homeostasis and the three major methods to quantify acid-base disorders - the physiological approach, base-excess approach, and physicochemical approach.
2. The normal ranges for parameters in an ABG report like pH, PaCO2, PaO2, HCO3, and SaO2.
3. A step-wise approach to solving acid-base disorders, including assessing validity, determining if there is acidemia or alkalemia, identifying the primary disorder, assessing compensation, calculating anion gap, and calculating delta gap to
Fluid responsiveness in critically ill patientsUbaidur Rahaman
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
The Global Initiative for Asthma (GINA) is an independent organization established by the WHO and NHLBI in 1993 to increase awareness of asthma and improve asthma prevention and management through coordinated global efforts. GINA publishes annual evidence-based strategy reports that provide practical guidance on asthma diagnosis and treatment that can be adapted for local health systems. The 2022 report includes updates to the diagnostic approach for patients taking controller treatment and emphasizes using low-dose ICS-formoterol as reliever therapy to reduce exacerbation risk compared to SABA relievers.
This document discusses pediatric ventilation basics including anatomy, physiology, pathophysiology, and terminology. Key points include: the pediatric airway is smaller and more anteriorly placed; children have higher oxygen needs and lower tolerance for hypoxia; compliance is lower in children; and ventilator settings like tidal volume, rate, inspiratory time, and PEEP must be adjusted for pediatric patients. Common pediatric lung conditions and how they impact pulmonary function tests and the ventilation/perfusion ratio are also reviewed.
The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.
This document discusses neonatal cardiac failure, including the pathophysiology of atrioventricular septal defect. It notes that the neonatal myocardium is anatomically different from the mature heart, with less organized myofibrils and contractile efficiency. This makes the neonatal heart more dependent on compensatory mechanisms like neurohormonal activation and the Frank-Starling response. Medical management aims to reduce afterload and preload on the heart through diuretics and ACE inhibitors while providing respiratory support. Surgical intervention may be needed to correct underlying structural defects.
Tetralogy of Fallot (TOF) is a heart defect present at birth where four structures in the heart are abnormal, resulting in deoxygenated blood flowing from the heart to the body. Babies with TOF often appear blue due to the lack of oxygen in their blood. The defects can cause obstruction of blood flow to the lungs. Treatment involves open heart surgery to repair the defects, after which symptoms usually improve. Lifelong follow-up care is important to monitor for complications.
Balanced solution is a boon for fluid resuscitationdr nirmal jaiswal
Balanced crystalloids are emerging as the fluid of choice for resuscitation over normal saline. Normal saline can cause hyperchloremic acidosis due to its high chloride content. Balanced crystalloids more closely mimic the electrolyte composition of plasma. Studies show balanced crystalloids may reduce complications like renal injury and need for renal replacement therapy compared to normal saline in critically ill patients. The optimal fluid choice depends on factors like the patient's clinical condition, electrolyte levels, and volume needed.
Non-Invasive Ventilation for Preterm InfantsMark Weems
This document discusses non-invasive ventilation techniques for preterm infants. It begins with a brief history of ventilation methods, including early attempts at non-invasive oxygen delivery and invasive techniques like intubation that introduced complications. More recent non-invasive methods described include high-flow nasal cannula (HFNC), nasal continuous positive airway pressure (NCPAP), and non-invasive positive pressure ventilation (NIPPV). Several studies comparing these techniques are summarized, finding that NCPAP and well-designed NIPPV protocols can reduce the need for intubation and the risk of bronchopulmonary dysplasia compared to early intubation and ventilation. Precise delivery of pressures using the Ram Cannula interface is also discussed.
This document summarizes several clinical trials related to critical care medicine. It discusses trials on topics such as decompressive craniectomy for traumatic brain injury, hypothermia for traumatic brain injury, erythropoietin for brain injury, blood pressure management for intracerebral hemorrhage, vasopressin versus norepinephrine for septic shock, dexmedetomidine for delirium, timing of renal replacement therapy for acute kidney injury, acetazolamide for chronic obstructive pulmonary disease, paracetamol for fever, balanced fluids versus saline, and transfusion thresholds.
This document discusses rational surfactant therapy. It begins by establishing that surfactant replacement therapy works based on multiple randomized controlled trials showing reductions in mortality, duration of ventilation and hospital stay. It describes the types of surfactants available and recommends natural surfactants. The document discusses the timing of surfactant replacement, benefits of multiple doses, and synergistic effects with antenatal steroids. Ventilatory management after surfactant including INSURE technique is covered, along with risks of the therapy.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
HFNC therapy provides high flow oxygen through a nasal cannula. It has several benefits over traditional oxygen delivery methods, including more accurate oxygen delivery, washout of dead space, and generation of positive end-expiratory pressure. HFNC is a well-tolerated therapy that can be used for hypoxemic respiratory failure, pre-intubation, and post-extubation. While promising, further research is still needed to establish clear guidelines for its use.
This document discusses different types of blood components used in transfusion therapy. It describes fresh whole blood, packed red blood cells (PRBCs), platelet concentrates, plasma components like fresh frozen plasma and cryoprecipitate. It provides details on the preparation, storage conditions and indications for transfusion of these various components. Guidelines for PRBC transfusion thresholds in preterm neonates and children with chronic anemias are also summarized.
This document discusses non-invasive ventilation (NIV) in neonates. It begins by defining NIV and describing the different modes including nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP). It reviews the evidence that NIPPV compared to NCPAP reduces extubation failure rates, failure rates as a primary respiratory mode, and mortality/bronchopulmonary dysplasia. The document provides guidelines for using NIPPV as a primary respiratory mode in preterm infants.
Fluid administration is commonly used to resuscitate ICU patients, but determining which patients will respond to fluids, known as fluid responsiveness, remains challenging. Static parameters like CVP are poor predictors of fluid responsiveness. Dynamic parameters that measure beat-to-beat variations related to mechanical ventilation, such as PPV, SVV, IVC collapsibility, and changes in aortic blood flow with PLR have been shown to more accurately predict fluid responsiveness with sensitivities and specificities often over 90%. However, factors like arrhythmias, spontaneous breathing, and suboptimal ventilator settings can limit the reliability of dynamic parameters in some clinical situations.
Fetal lung development is a complex process that begins in the first trimester of pregnancy and continues after birth. It occurs through five overlapping stages: embryonal, pseudoglandular, canalicular, saccular, and alveolar. While the basic structure of the lungs is established before birth, significant development, including alveolar multiplication and increases in surface area, continues postnatally through childhood. After birth, the lungs must adapt to extrauterine life and breathing, with over 80% of adult alveoli forming in the first years of life. This postnatal growth and cellular differentiation are crucial for the lungs to achieve full maturity and function.
This document discusses patient blood management (PBM), which is a multidisciplinary approach to optimizing patient care and reducing unnecessary blood transfusions. It has three pillars: optimizing erythropoiesis, minimizing bleeding, and harnessing physiological reserves of anemia. The evidence shows PBM can reduce transfusions by 39% without increasing risks. It has led to reduced transfusions and costs in various settings like cardiac and orthopedic surgery. PBM programs require a multidisciplinary team approach led by specialties like anesthesiology. Overall, PBM provides better patient outcomes while reducing allogeneic blood use.
A brief presentation about the current evidence based medical knowledge about the use of salt free albumin . After finishing this presentation you might discover that a lot of our practice lacks a solid basis regarding the use of this expensive drug.
This document provides an overview of lung ultrasound scanning techniques and findings. It discusses how to optimize scanner settings and probe positioning for lung scans. Key scanning points on the chest are described, including the BLUE and PLAPS points. Normal lung appearances and artifacts are explained. Pathological findings covered include pleural fluid, B-lines indicating interstitial syndrome, the lung sliding sign, and alveolar consolidation. The document emphasizes comparing both sides of the chest and using M-mode to help diagnose a pneumothorax based on the absence of lung sliding and B-lines.
This document discusses acid-base disorders and interpretation of arterial blood gases (ABGs) and spirometry. It provides:
1. An overview of acid-base homeostasis and the three major methods to quantify acid-base disorders - the physiological approach, base-excess approach, and physicochemical approach.
2. The normal ranges for parameters in an ABG report like pH, PaCO2, PaO2, HCO3, and SaO2.
3. A step-wise approach to solving acid-base disorders, including assessing validity, determining if there is acidemia or alkalemia, identifying the primary disorder, assessing compensation, calculating anion gap, and calculating delta gap to
Fluid responsiveness in critically ill patientsUbaidur Rahaman
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
The Global Initiative for Asthma (GINA) is an independent organization established by the WHO and NHLBI in 1993 to increase awareness of asthma and improve asthma prevention and management through coordinated global efforts. GINA publishes annual evidence-based strategy reports that provide practical guidance on asthma diagnosis and treatment that can be adapted for local health systems. The 2022 report includes updates to the diagnostic approach for patients taking controller treatment and emphasizes using low-dose ICS-formoterol as reliever therapy to reduce exacerbation risk compared to SABA relievers.
This document discusses pediatric ventilation basics including anatomy, physiology, pathophysiology, and terminology. Key points include: the pediatric airway is smaller and more anteriorly placed; children have higher oxygen needs and lower tolerance for hypoxia; compliance is lower in children; and ventilator settings like tidal volume, rate, inspiratory time, and PEEP must be adjusted for pediatric patients. Common pediatric lung conditions and how they impact pulmonary function tests and the ventilation/perfusion ratio are also reviewed.
The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.
This document discusses neonatal cardiac failure, including the pathophysiology of atrioventricular septal defect. It notes that the neonatal myocardium is anatomically different from the mature heart, with less organized myofibrils and contractile efficiency. This makes the neonatal heart more dependent on compensatory mechanisms like neurohormonal activation and the Frank-Starling response. Medical management aims to reduce afterload and preload on the heart through diuretics and ACE inhibitors while providing respiratory support. Surgical intervention may be needed to correct underlying structural defects.
Tetralogy of Fallot (TOF) is a heart defect present at birth where four structures in the heart are abnormal, resulting in deoxygenated blood flowing from the heart to the body. Babies with TOF often appear blue due to the lack of oxygen in their blood. The defects can cause obstruction of blood flow to the lungs. Treatment involves open heart surgery to repair the defects, after which symptoms usually improve. Lifelong follow-up care is important to monitor for complications.
Balanced solution is a boon for fluid resuscitationdr nirmal jaiswal
Balanced crystalloids are emerging as the fluid of choice for resuscitation over normal saline. Normal saline can cause hyperchloremic acidosis due to its high chloride content. Balanced crystalloids more closely mimic the electrolyte composition of plasma. Studies show balanced crystalloids may reduce complications like renal injury and need for renal replacement therapy compared to normal saline in critically ill patients. The optimal fluid choice depends on factors like the patient's clinical condition, electrolyte levels, and volume needed.
Non-Invasive Ventilation for Preterm InfantsMark Weems
This document discusses non-invasive ventilation techniques for preterm infants. It begins with a brief history of ventilation methods, including early attempts at non-invasive oxygen delivery and invasive techniques like intubation that introduced complications. More recent non-invasive methods described include high-flow nasal cannula (HFNC), nasal continuous positive airway pressure (NCPAP), and non-invasive positive pressure ventilation (NIPPV). Several studies comparing these techniques are summarized, finding that NCPAP and well-designed NIPPV protocols can reduce the need for intubation and the risk of bronchopulmonary dysplasia compared to early intubation and ventilation. Precise delivery of pressures using the Ram Cannula interface is also discussed.
This document summarizes several clinical trials related to critical care medicine. It discusses trials on topics such as decompressive craniectomy for traumatic brain injury, hypothermia for traumatic brain injury, erythropoietin for brain injury, blood pressure management for intracerebral hemorrhage, vasopressin versus norepinephrine for septic shock, dexmedetomidine for delirium, timing of renal replacement therapy for acute kidney injury, acetazolamide for chronic obstructive pulmonary disease, paracetamol for fever, balanced fluids versus saline, and transfusion thresholds.
This document discusses rational surfactant therapy. It begins by establishing that surfactant replacement therapy works based on multiple randomized controlled trials showing reductions in mortality, duration of ventilation and hospital stay. It describes the types of surfactants available and recommends natural surfactants. The document discusses the timing of surfactant replacement, benefits of multiple doses, and synergistic effects with antenatal steroids. Ventilatory management after surfactant including INSURE technique is covered, along with risks of the therapy.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
HFNC therapy provides high flow oxygen through a nasal cannula. It has several benefits over traditional oxygen delivery methods, including more accurate oxygen delivery, washout of dead space, and generation of positive end-expiratory pressure. HFNC is a well-tolerated therapy that can be used for hypoxemic respiratory failure, pre-intubation, and post-extubation. While promising, further research is still needed to establish clear guidelines for its use.
This document discusses different types of blood components used in transfusion therapy. It describes fresh whole blood, packed red blood cells (PRBCs), platelet concentrates, plasma components like fresh frozen plasma and cryoprecipitate. It provides details on the preparation, storage conditions and indications for transfusion of these various components. Guidelines for PRBC transfusion thresholds in preterm neonates and children with chronic anemias are also summarized.
This document discusses non-invasive ventilation (NIV) in neonates. It begins by defining NIV and describing the different modes including nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP). It reviews the evidence that NIPPV compared to NCPAP reduces extubation failure rates, failure rates as a primary respiratory mode, and mortality/bronchopulmonary dysplasia. The document provides guidelines for using NIPPV as a primary respiratory mode in preterm infants.
Fluid administration is commonly used to resuscitate ICU patients, but determining which patients will respond to fluids, known as fluid responsiveness, remains challenging. Static parameters like CVP are poor predictors of fluid responsiveness. Dynamic parameters that measure beat-to-beat variations related to mechanical ventilation, such as PPV, SVV, IVC collapsibility, and changes in aortic blood flow with PLR have been shown to more accurately predict fluid responsiveness with sensitivities and specificities often over 90%. However, factors like arrhythmias, spontaneous breathing, and suboptimal ventilator settings can limit the reliability of dynamic parameters in some clinical situations.
Fetal lung development is a complex process that begins in the first trimester of pregnancy and continues after birth. It occurs through five overlapping stages: embryonal, pseudoglandular, canalicular, saccular, and alveolar. While the basic structure of the lungs is established before birth, significant development, including alveolar multiplication and increases in surface area, continues postnatally through childhood. After birth, the lungs must adapt to extrauterine life and breathing, with over 80% of adult alveoli forming in the first years of life. This postnatal growth and cellular differentiation are crucial for the lungs to achieve full maturity and function.
This document discusses patient blood management (PBM), which is a multidisciplinary approach to optimizing patient care and reducing unnecessary blood transfusions. It has three pillars: optimizing erythropoiesis, minimizing bleeding, and harnessing physiological reserves of anemia. The evidence shows PBM can reduce transfusions by 39% without increasing risks. It has led to reduced transfusions and costs in various settings like cardiac and orthopedic surgery. PBM programs require a multidisciplinary team approach led by specialties like anesthesiology. Overall, PBM provides better patient outcomes while reducing allogeneic blood use.
A brief presentation about the current evidence based medical knowledge about the use of salt free albumin . After finishing this presentation you might discover that a lot of our practice lacks a solid basis regarding the use of this expensive drug.
This document provides an overview of lung ultrasound scanning techniques and findings. It discusses how to optimize scanner settings and probe positioning for lung scans. Key scanning points on the chest are described, including the BLUE and PLAPS points. Normal lung appearances and artifacts are explained. Pathological findings covered include pleural fluid, B-lines indicating interstitial syndrome, the lung sliding sign, and alveolar consolidation. The document emphasizes comparing both sides of the chest and using M-mode to help diagnose a pneumothorax based on the absence of lung sliding and B-lines.
This document discusses pediatric clinical chemistry and provides definitions related to different pediatric age groups. It summarizes reference intervals and clinical conditions evaluated in pediatrics, including fetal maturity and lung development. Key tests discussed include the L/S ratio test to evaluate fetal lung surfactant maturity, tests to diagnose premature rupture of membranes, and evaluation of blood gases, electrolytes, liver function, and other important analytes in pediatrics. Sampling considerations and point-of-care testing in pediatrics are also summarized.
Abnormal liver function tests can indicate underlying liver disease but may also be caused by extrahepatic factors. A thorough evaluation is needed and includes considering the pattern of test abnormalities, severity of changes, and potential etiologies. For hepatocellular predominant abnormalities, further workup may include tests for viral hepatitis, autoimmune disease, and iron overload. Liver biopsy may be needed if initial testing is unrevealing. Proper diagnosis guides management and treatment of underlying liver conditions.
1. Critical care ultrasound can rapidly diagnose conditions in critically ill patients to guide treatment when other diagnostic tests are unavailable or too slow.
2. A case example is presented of a patient presenting with breathing difficulties where ultrasound identified a massive pulmonary embolism when other tests were inconclusive or too slow.
3. The key applications of critical care ultrasound are a quick scan of the lungs, inferior vena cava, and heart to assist diagnosis and resuscitation in unstable patients.
The document discusses critical care, describing the intensive care team, critical care nursing, the seven Cs of critical care, and the roles of critical care nurses, units, and physicians. It outlines staffing requirements for critical care units, including nurses, respiratory therapists, and physician subspecialists who should be available to treat critically ill patients.
slideworld - Medical powerpoint search Enginerinki singh
Slideworld is a medical powerpoint search engine.Slideworld was founded by a team of international doctors to cater to the needs of the medical community looking for authoritative content in a concise format related to various medical topics.Search and share millions of medical powerpoint presentations.
Critical care nursing involves caring for patients with life-threatening illnesses or injuries. It requires thorough observation, intensive nursing care, and management of complex equipment and medications. Critical care nurses provide one-on-one care for critically ill patients in specialized units like intensive care units (ICUs). Their role is highly demanding but crucial for making important decisions that can mean life or death. Critical care has evolved over time with advances in technology and the development of ICUs to treat critically ill patients following World War II and the polio epidemic.
This document provides an overview of mechanical ventilation, including:
1) How mechanical ventilation helps reduce the work of breathing and restore gas exchange through invasive and noninvasive positive pressure ventilation.
2) The basics of monitoring pressure, volume, flow, and pressure-time curves at the bedside.
3) Important considerations for mechanical ventilation including potential adverse effects on hemodynamics, lungs, and gas exchange, and how to address issues like auto-PEEP.
Hot Topics in Critical Care - March 2017Steve Mathieu
This document summarizes several recent randomized controlled trials in critical care medicine:
1. A trial comparing high-flow nasal cannula to standard oxygen therapy in patients post-abdominal surgery found no difference in rates of hypoxemia or other outcomes.
2. A trial of intravenous iron in anemic critically ill patients found higher hemoglobin levels at discharge but no difference in transfusion requirements.
3. A trial of dexmedetomidine in elderly surgery patients reduced delirium rates compared to placebo.
This document discusses recent advances in the management of pediatric septic shock. It summarizes that evidence is shifting away from protocolized care to more individualized, physiology-based approaches. Specifically, the evidence no longer supports aggressive fluid resuscitation and liberal blood transfusions. Instead, more conservative fluid and transfusion strategies are favored. The document also reviews new evidence regarding use of biomarkers, inotrope selection, antibiotic timing, and steroid use in managing pediatric septic shock.
This document discusses nutrition and fluid therapy in the peri-operative period. It covers several topics:
- The normal distribution of water in the body and barriers between fluid compartments.
- Developments in fluid management practices from liberal to restrictive/goal-directed strategies.
- Evidence that crystalloids are preferred to colloids and balanced solutions to saline for fluid therapy.
- Techniques for assessing fluid status and predicting fluid responsiveness like fluid challenges.
- The importance of considering both macrocirculation and microcirculation in fluid management.
- Guidelines for perioperative nutritional support based on albumin levels and optimal enteral feeding.
This article summarizes a study that evaluated the efficacy and safety of bosentan for pulmonary arterial hypertension. The study found that patients treated with bosentan had improved exercise capacity and pulmonary function compared to placebo, as well as reduced clinical worsening. Bosentan was well tolerated at a dose of 125 mg twice daily and showed benefits for pulmonary arterial hypertension patients. Long-term experience with bosentan is still needed, but initial results suggest it is an effective oral therapy for pulmonary arterial hypertension.
3.blood and its current concepts in coagulationAminah M
This document provides an overview of blood and its components. It discusses the properties and functions of plasma, red blood cells, white blood cells, platelets, and hemoglobin. Specific topics covered include blood composition, plasma proteins, red blood cell development and lifespan, hematological indices, hemoglobin structure and function, anemias, and polycythemias. Reference texts on medical physiology are cited throughout.
Perioperative fluid management in children:Is dilemma solved?anujkarki
1) Perioperative fluid management in children has historically been challenging due to the risk of electrolyte imbalances and hyponatremia from hypotonic solutions.
2) More recent guidelines recommend using isotonic solutions with sodium and chloride concentrations close to physiological ranges and lower glucose concentrations of 1-2.5% to avoid these issues.
3) While maintenance fluid rates, accounting for deficits, and replacing third space losses continue to be debated, current recommendations favor more conservative individualized fluid management and goal-directed approaches over standard formulas or replacing high estimated losses. The optimal intraoperative fluid volume remains an area of ongoing discussion.
The document summarizes various alternatives to blood transfusion, including oxygen carrying solutions, hemoglobin based oxygen carrying solutions (HBOCS), perflourocarbons, antigen camouflage techniques, recombinant plasma proteins, and transgenic platelet substitutes. It discusses the advantages and challenges of each approach, such as universal compatibility with oxygen carriers but side effects with HBOCS including vasoactivity and gastrointestinal issues.
The document discusses various alternatives to blood transfusion, including hemoglobin-based oxygen carriers, perfluorocarbon oxygen carriers, antigen camouflage techniques, recombinant plasma proteins from transgenic animals, and potential platelet substitutes such as synthocytes and infusible platelet membranes. While these alternatives aim to address issues with blood supply and safety, each method still faces challenges with side effects, availability, and clinical efficacy that have prevented widespread use.
Albumin versus fresh frozen plasma in managing diuretic resistant edema in ch...iosrphr_editor
This study was carried out to compare the efficacy, cost effectiveness and outcome of albumin with fresh frozen plasma (FFP) in the treatment of diuretic resistant edema in childhood idiopathic nephrotic syndrome.Methods: Fifty four patients with idiopathic NS were enrolled in this prospective analytic study. Patients with moderate to severe edema with serum albumin <15 gm/L were given albumin and FFP dividing into two groups. Group-A, received intravenous albumin- 1 gm/kg/day and Group-B intravenous FFP 15ml/kg/day. Total number of albumin and FFP infusion were determined by edema reduction. Cost effectiveness was also calculated. Results: Diagnosis of NS and biochemical parameters were same in both groups. Dry weight was achieved in Group-A in 6.66± 3.710 days and in Group-B 6.66± 3.038 days. In Group-A the number of albumin infusion required was 1.44±0.697 and Group-B FFP infusion required was 3.11± 1.5 (p=0.0001). Group A needed 4608.00 ($57.6) taka for albumin whereas Group B needed only 2177.00($ 27.2) taka for FFP (p=0.0001). No significant complications were observed in both the groups.Conclusion: FFP costs half than albumin and same duration required reducing edema but the cost-effectiveness may place FFP as a better choice especially in developing countries of the world.
This document discusses the validation of oxygen saturation monitoring in neonates. The objective of the study was to validate whether clinical monitors correctly recorded oxygen saturation levels in neonates by comparing the monitor readings to blood samples. The study included neonates in the neonatal intensive care unit who were born with respiratory distress or other issues requiring oxygen therapy. Blood samples were taken from umbilical arteries and veins to obtain oxygen levels and compare to monitor readings placed on the neonates' feet.
Relief from hot flushes is one of the most common reasons for visits from mid-life women and represents a major healthcare cost. Hot flushes are associated with poor sleep, depressed mood, decreased quality of life, and may increase risk of cardiovascular disease and poor bone health. A standardized hop extract containing 8-PN (8-prenylnaringenin) at 100 mcg per day provided relief for mild vasomotor symptoms and was well tolerated by menopausal women in clinical studies. 8-PN begins changing hormone balance after a single dose and shows potential benefits for breast health, cardiovascular health, and bone health when consumed as part of a balanced diet and lifestyle.
This document summarizes a presentation on therapeutic plasma exchange (PEX) given by Kamal Mohamed Okasha. It provides an overview of the PEX procedure and potential indications for PEX, including Goodpasture's Syndrome, thrombotic thrombocytopenic purpura, cryoglobulinemia, multiple myeloma, and ANCA disease. It discusses complications of PEX and guidelines for efficacy based on recent studies. In particular, it examines the use of PEX for Goodpasture's Syndrome, noting that PEX aims to remove circulating anti-GBM antibodies and that studies have found improved outcomes, including renal function and survival, for patients receiving PEX treatment.
This document discusses fluid management strategies in traumatic brain injury (TBI). It summarizes that:
1) Both hypotension and hypoalbuminemia are associated with worse outcomes in TBI patients and should be avoided.
2) While aggressive fluid resuscitation is generally recommended to maintain cerebral perfusion pressure, excessive or hypotonic fluids can worsen brain edema.
3) Evidence on optimal resuscitation fluids is limited, but albumin may not be preferable to saline in TBI patients based on prior studies. Hypertonic solutions show promise but require further research to define best practices.
This research article compares the effectiveness of oral versus intravenous proton pump inhibitors (PPIs) in preventing re-bleeding in patients with peptic ulcer bleeding after successful endoscopic therapy. 100 patients were randomly assigned to receive either oral lansoprazole or intravenous esomeprazole after endoscopic hemostasis. The re-bleeding rates within 14 days were similar between the two groups. Patients receiving oral PPI had a shorter hospital stay. While no differences in clinical outcomes were found, the study was not powered to prove equivalence between the oral and intravenous PPI treatments. Larger studies are still needed to further compare the effectiveness of oral versus intravenous PPI administration.
This study analyzed 621 patients with acute heart failure (AHF) admitted to the intensive care unit to evaluate the clinical significance of acid-base balance in an emergency setting. The results showed factors associated with acidosis included high white blood cell count, glucose, blood pressure, and heart rate. Factors linked to alkalosis were high C-reactive protein, bilirubin, and low albumin. Patients with alkalosis were less likely to have orthopnea and had lower blood pressure and heart rate. Alkalosis was an independent risk factor for in-hospital mortality and poorer long-term survival rates compared to patients with normal acid-base balance.
This study investigated the effect of mild normovolemic anemia on wound healing in rabbits. The researchers found that:
1) Wound fluid oxygen tensions and pH were identical between anemic and control rabbits, indicating anemia did not decrease oxygen supply to wounds.
2) Anemic rabbits produced 12% more connective tissue in wounds compared to controls, as measured by dry weight.
3) Mild normovolemic anemia on its own does not impair wound healing and oxygen delivery, likely due to compensatory mechanisms that help maintain adequate oxygen transport. Blood transfusion may not be necessary for optimal healing of wounds when anemia is mild and uncomplicated.
The four phases of intravenous fluid therapy: Manu MalbrainSMACC Conference
This document discusses fluid management in intensive care patients. It notes that fluids are drugs that require appropriate dosing, timing, and de-escalation. Inappropriate fluid therapy can lead to hyperchloremic metabolic acidosis, acute kidney injury, and increased mortality. The key factors in empiric fluid therapy are considering patient risk factors for fluid overload and targeting fluids specifically for resuscitation, maintenance, or replacement needs rather than focusing solely on hemodynamic parameters. Fluid removal should begin when shock is resolved to avoid complications from fluid overload.
Similar to Albumin in pediatric critical care (20)
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
Thinking of getting a dog? Be aware that breeds like Pit Bulls, Rottweilers, and German Shepherds can be loyal and dangerous. Proper training and socialization are crucial to preventing aggressive behaviors. Ensure safety by understanding their needs and always supervising interactions. Stay safe, and enjoy your furry friends!
1. Role of Albumin in PICU
DR FARHANSHAIKH
Consultant Pediatric Intensivist
In-charge Quality and Accreditation
Rainbow Children’s Hospital
Hyderabad
2. WHY ALBUMIN IS “HOT” TOPIC?
• A search of word ALBUMIN on pubmed yields
199,905 results !
• Search word “Hemoglobin” yields 155311
results!
• Almost 40% of all the publications on albumin
have been concentrated in the last 10 years
3. Physiology and pathophysiology of
albumin in humans
• Molecular weight of
66,500 Daltons,
• Albumin is responsible
for about 80% of the
intravascular oncotic
pressure.
Weil MH, Henning RJ, Puri VK. Colloid oncotic pressure: clinical significance. Crit Care
Med 1979;7:113-6
4. • The liver produces albumin, which is
immediately secreted into the intravascular
space by the cells without being stored.
• From the intravascular space, albumin passes
into the interstitial space to different degrees
and at different rates depending on the
anatomical location, in a process called
"transcapillary filtration”.
5. • In regions where endothelium has large gaps,
the filtration of albumin is passive
• In regions where endothelium is nonfenestrated Albumin filtration is active, under
the particular action of a specific receptor, i.e.,
“albondin”.
6. Molecular structure of albumin
Three main characteristics
(i) cysteine residues
(ii) domains I and II and
(iii) imidazole residues.
7. How Albumin Helps?
The oncotic properties of this protein play a
critical role in regulating volaemic status
particularly during adverse clinical conditions
where volaemia is very often altered.
8. • Cysteine residues in position 34 expose a –SH
radical group (thiol), which is one of the main
extracellular antioxidants.
• Moreover, –SH residues bind nitric oxide to
form S-nitrous thiols, thereby neutralizing one
of the most important mediators of
pathological conditions mainly sepsis
9. Albumin may also neutralize the vasodilating
effect of nitric oxide, which is the most
important mediator altering vascular tone
during sepsis or other pathological conditions
such as hepat-orenal syndrome
10. Albumin domains I and II are responsible for
the transport of the numerous molecules, both
endogenous and exogenous, that are
extensively carried by human albumin.
11. • Finally, albumin has 16 histidine imidazole
residues, which are responsible for the “buffer
function” of albumin.
• Having a pH of about 6.75, the residues may
both give up or accept H+ from the
environment depending on the surrounding
pH, thereby acting as a buffer molecule.
15. This Cochrane report based on a meta-analysis
suggested the potentially harmful effect of
albumin administration as compared to other
fluids for volume replacement
16. The meta-analysis, included 32 clinical trials
involving a total of 1,419 patients, and showed,
among patients with surgery- or trauma-induced
hypovolaemia, no differences in mortality
between those treated with albumin and those
treated with crystalloids.
17. In fact, patients with burns who were treated
with albumin appeared to have a higher
mortality rate as compared to those treated
with crystalloids.
18. The authors concluded..
"There is no evidence that the administration of
albumin reduces mortality in critically ill patients
with hypovolemia, burns, hypoalbuminemia, but
rather a strong indication that it increases
mortality”
This led to an extensive reduction of
the use of albumin in some countries
Use of Albumin in Intensive Care Units in the United Kingdom
J. M. BROWN et al. Critical Care and Resuscitation 2001; 3: 19-21
19. Meta-analysis published in 2001, concluding that
ALBUMIN ADMINISTRATION WAS SAFE, although it had no
effects on global mortality.
20. A third meta-analysis, which included nine prospective,
randomized clinical trials on critically ill patients with
hypoalbuminaemia, was concluded and published in 2003.
22. The authors concluded :
"Currently there is no reason for not administering
albumin when clinically appropriate."
23.
24. • The first metanalysis appeared to be AGAINST
• The second one was NEUTRAL and
• The third one was IN FAVOUR of the clinical use
of albumin.
25. WHY THIS CONTROVERSY..??
• Many Heterogenous studies with
heterogeneous patient selection
• The point in time at which fluid was
administered to patients enrolled in these
trials could have been crucial.
26. anti- oxidant paradox effect
• A good anti-oxidant is a reducing agent.
• Oxidative damage releases transition metals
from damaged metallo-proteins.
• By reducing these transition metals, an antioxidant administered after damage has
started can create more reactive species
which catalyse ROS formation.
27. Higher doses of albumin, and
Its Delayed administration,
May not BE comparable
with LOWER DOSES AND
ITS early Administration
Hypoalbuminemia in Acute Illness: Is There a Rationale for Intervention?
A Meta-Analysis of Cohort Studies and Controlled Trials. Jean-Louis Vincent et al
ANNALS OF SURGERY Vol. 237, No. 3, 319–334
28. Study protocols also varied with regard to fluid
volume administration:
• some used fixed doses,
• others targeted cardiovascular parameters or
metabolic markers of perfusion and
• others allowed clinical discretion.
29. EVERY ALBUMIN IS NOT SAME!!
Albumin from different batches of the same
product contain molecules with a wide range of
variable post-translational modifications
including ..
• glycosylation,
• missing terminal amino acids and
cysteinylation and nitrosilation of the free
cysteine residue
Bar-Or D, Bar-Or R, Rael LT et al. Heterogeneity and oxidation status of
commercial human albumin preparations in clinical use. Crit Care Med 2005;33:1638-41.
30. • Some of these variations lead to a loss of
oxidant-buffering capacity, and abolish the
molecules’ ability to chelate free copper.
• Thus clinical effects may vary and this can
seriously affect the final outcome.
• Genetically engineered recombinant Albumin
may eliminate such variations and allow more
predictable clinical outcomes.
Hypoalbuminemia in Acute Illness: Is There a Rationale for Intervention?
A Meta-Analysis of Cohort Studies and Controlled Trials. Jean-Louis Vincent et al
ANNALS OF SURGERY Vol. 237, No. 3, 319–334
32. The SAFE study
16 ICU in Australia and New Zealand conducted
a prospective, randomized, double- blind study,
the Saline vs. Albumin Evaluation (SAFE) study
The study compared the effects of the infusion
of 4% albumin and saline solution (0.9% NaCl)
for volume replacement in critically ill patients
with hypovolemia
Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid
resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56
33. About 7,000 patients were enrolled.
Three predefined subgroups of patients with
specific diseases i.e.
• sepsis,
• trauma and
• acute respiratory distress syndrome.
34. No difference in 28-day mortality, length of stay, or
organ dysfunction was observed between the groups
of patients receiving the two different treatment.
35. Thus, clearly demonstrating that 4% albumin
infusion for volume replacement in critically ill
patients does not offer any advantage as
compared to normal saline, or, in other words,
that albumin administration is "safe".
Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid
resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56
36. Albumin may be as safe as Saline, but
that does not mean Albumin is better !
Agreed..
However..
• The SAFE study was not designed to
investigate possible beneficial effects of
albumin
• The amount of study fluid was relatively
limited.
37. The great contribution of the SAFE study came
from the subgroup analysis performed
• The patients with trauma, especially after
head injury, treated with albumin tended to
have a higher mortality rate (P = 0.06)
• those with severe sepsis tended to show a
better survival, although the difference did
not reach statistical significance (P = 0.09).
38. SAFE study, for the first time, turned the
attention of researchers towards the possible
crucial role of different categories of patients,
when dealing with the type of fluid to be
employed for volume replacement.
39. Patients with traumatic brain injury
A post- hoc follow-up of the patients with
traumatic brain injury previously enrolled in the
SAFE study,
Higher mortality was observed in patients with
severe traumatic brain injury, with mortality
rates of 41.8% and 22.2% in patients treated
with albumin or saline, respectively (p < 0.001)
40. The authors, therefore, concluded that
“critically ill patients with traumatic brain
injury, fluid resuscitation with albumin was
associated with higher mortality rates than was
resuscitation with saline"
41. Hypoalbuminemia Vs Mortality
Many studies in children as well as adults have
demonstrated strong association between
hypoalbuminemia and mortality
Powers KA, Kapus A, Khadaroo RG, et al. Twenty-five percent albumin prevents lung injury
following shock/ resuscitation. Crit Care Med 2003;31:2355-63.
Goldwasser P, Feldman J. Association of serum albumin and mortality risk.
J Clin Epidemiol 1997;50:693-703. 38) Roberts I, Bunn F. Egg on their faces.
The story of human albumin solution. Eval Health Prof 2002; 25:130-8.
43. This study investigated the hypothesis that
correcting hypoalbuminaemia in critically ill
patients in an attempt to maintain plasma
albumin concentration within the normal range
(greater than 3 g/dL) may have beneficial effects
on organ function.
44. In Dubois study, patients were randomized to
receive 300 mL of 20% albumin solution on the
first day after randomization and 200 mL/day if
their plasma albumin concentration was lower
than 3 g/dL in the treated group, or to receive
no albumin infusion in the control group.
Crit Care Med 2006;34:2536-40.
45. The authors, concluded that
"Albumin administration may improve organ
function in hypoalbuminaemic critically ill
patients"
Crit Care Med 2006;34:2536-40.
46. This study provided, for the first time, some
evidence about the critical role of maintaining
plasma albumin concentrations within a normal
range, throughout the ICU admission, with a
possible impact on organ function.
48. This systematic review includes the results of four recent randomized clinical trials of
HES 130/0.38-0.45 comprising more than 3000 patients with sepsis
49. The study showed Hydroxy Ethyl Starch
increased…
• the use of renal replacement therapy
• transfusion with red blood cells,
• Resulted in more serious adverse events
inpatients with sepsis.
50. The authors concluded that..
“It seems unlikely that hydroxyethyl starch
provides overall clinical benefit for patients with
sepsis”.
51. Clinical indications of using Albumin
Three important categories can be made:
• Patients with traumatic brain injury,
• Patients with peripheral oedema during their
recovery phase, and
• Patients with severe sepsis.
52. Patients with traumatic brain injury
Patients with an active brain injury due to
cerebral trauma, albumin administration should
be avoided, preferring other types of fluids, such
as normal saline, for acute volume resuscitation.
53. Patients with peripheral oedema
during their recovery phase
In using crystalloids for volume replacement, the
most important disadvantage is ..
• the greater amount of fluids to be infused in
order to reach the same volume effect of
albumin or other synthetic colloids
• a consequent increased risk of peripheral
oedema and weight gain.
54. Artificial colloids
• Not found to be beneficial in sepsis
• May cause coagulopathy, because of
absorption of the factor VII/von Willebrand
factor complex,
• May lead to an increased risk of developing
acute renal failure.
de Jonge E, Levi M. Effects of different plasma substitutes on blood coagulation:
a comparative review. Crit Care Med 2001;29:1261-7.
55. THEORATICALLY…
• During Acute phase , due to leaky capillaries even
Albumin can leak out of the blood vessels but
Albumin leaks slower than crystalloids thus
reducing overall fluid required for resuscitation.
(e.g. In Dengue Shock )
• During “recovery phase” as the capillaries
stabilize, and Albumin will hold on intravascularly
and improve the hemodynamics.
56. • Unfortunately, no clear evidence from
randomized clinical trials or other forms of
large studies are currently available in this
regard.
• However, the soundness of the biological and
pathophysiological rationale may at least
partially justify such an indication for albumin
administration.
57. Lack of evidence may not
necessarily exclude the
possible beneficial effect
58. In spite of no clear evidence from randomized
clinical trials Albumin can be considered useful in
patients with..
• marked hypoalbuminaemia,
• peripheral edema, and
• in serious need of water elimination, especially
in their recovery phase after acute volume
replacement.
(Severe edema in Nephrotic syndrome, Post
Cardio Pulmonary Bypass targetting Sr Albumin >
2.5gm% by Albumin transfusion and Diuretics)
59. The ALBIOS Study
(ALBumin Italian Outcome Sepsis)
• Recently completed recruiting 1,818 patients
fulfilling criteria for severe sepsis or septic
shock.
• All patients were resuscitated with crystalloids
according to early goal-directed therapy
protocols.
Gattinoni L, Caironi P. The AlbIOS Study. Newsletter 36. http://
www.negrisud.it/albios/news/newsletter_albios_36.pdf Accessed 28
March 2012.
60. • In addition, the intervention group received
300 mL 20% HAS on day 1 and further daily
infusions to maintain serum albumin at or
above 3 g/dL for the next 27 days.
• The primary outcome was originally 28-day
mortality, although this has been extended to
90 days.
61.
62.
63. • In patients with sepsis albumin infusion
compared to crystalloids alone provided
hemodynamic advantages, and more
favorable fluid balance without survival
benefits.
• In patients with septic shock, hemodynamic
fluid balance advantages were greater than in
general population and, in addition, these
patients survived significantly more at 90
days.
64. CONCLUSION
Apart from its oncotic properties, albumin may
be useful in critical care through its secondary
functions, such as..
• The modulating action on nitric oxide
metabolism
• free radical production
• its buffer effect in the acid-base equilibrium,
• its action as a transporter of many different
substances and drugs
65. Patients with severe sepsis
Although Albumin can leak through capillaries in
early shock but it will leak slower than
crystalloids, hence it can still be used during
acute shock state to reduce overall fluid
requirement.
During later stages, it will be beneficial in
maintaining oncotic pressure, fluid shifts.
66. Albumin may have a beneficial
impact..
• In patients with severe hypoalbuminaemia
and peripheral oedema
• During the recovery phase after acute volume
replacement
• On the elimination of the excessive
accumulated volume.
Editor's Notes
Although Hemoglobin is a far too important molecule, Albumin exceeds it by cool 50,000 results!!!
The lack of “albondin” in some anatomical compartments, such as the brain, accounts for the low concentration of this protein in the cerebrospinal fluid1
In this regard, it is evident how albumin concentration may be important when administering drugs with a high-binding affinity, especially during acute pathological processes usually characterised by hypoalbuminaemia. In these conditions, drug toxicity or even drug inefficiency may be observed33
Thus, although hypoalbuminaemia is very commonly observed in critically ill patients, the dilemma is whether this alteration may really have an impact on the outcome of such patients. In other words, the real question is whether the relationship between hypoalbuminaemia and mortality is a simple association or a cause-effect relation, and, if the latter is the case, what the best cure for hypoalbuminaemia is.
Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med 2001;135:149-64.
Vincent JL, Dubois MJ, Navickis RJ, Wilkes MM. Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials. Ann Surg 2003;237:319-34
The most commonly observed pathological alteration in albumin concentration in the critically ill is hypoalbuminaemia
In spite of no clear evidence from randomized clinical trials we may conclude in favor of a