Journal Reading SAFE - Emergency Medicine

7/28/2019 Journal Reading SAFE - Emergency Medicine

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Dina Yuniastuti 4151101097


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Abstract

Background

0The Saline versus Albumin Fluid Evaluation study suggested thatpatients with traumatic brain injury resuscitated with albumin had ahigher mortality rate than those resuscitated with saline. Weconducted a post hoc follow-up study of patients with traumatic braininjury who were enrolled in the study.

Methods

0For patients with traumatic brain injury (i.e., a history of trauma,evidence of head trauma on a computed tomographic [CT] scan, and a

score of

13 on the Glasgow Coma Scale [GCS]), we recorded baselinecharacteristics from case-report forms, clinical records, and CT scansand determined vital status and functional neurologic out- comes 24months after randomization.

N Engl J Med

2007;357:874-84The New England Journal of Medicine 2


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AbstractResults0We followed 460 patients, of whom 231 (50.2%) received albumin and

229 (49.8%) received saline. The subgroup of patients with GCS scores of

3 to 8 were classified as having severe brain injury (160 [69.3%] in the

albumin group and 158 [69.0%] in the saline group). Demographic

characteristics and indexes of severity of brain injury were similar atbaseline. At 24 months, 71 of 214 patients in the albumin group (33.2%)

had died, as compared with 42 of 206 in the saline group (20.4%) (relative

risk, 1.63; 95% confidence interval [CI], 1.17 to 2.26; P=0.003). Among

patients with severe brain injury, 61 of 146 patients in the albumin group

(41.8%) died, as compared with 32 of 144 in the saline group (22.2%)

(relative risk, 1.88; 95% CI, 1.31 to 2.70; P


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Abstract

Conclusions

0 In this post hoc study of critically ill patients with traumatic

brain injury, fluid resuscitation with albumin was associated with

higher mortality rates than was resuscitation with saline.(Current Controlled Trials number, ISRCTN76588266.)

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Discussion

0 Crystalloid-based fluid strategies are favored in trauma-

resuscitation protocols, although the evidence supporting these

strategies in cases of brain injury is limited. Most of these

protocols are based on a pragmatic approach to resuscitation, onthe assumption that prompt restoration of the volume of

circulating blood and the prevention of hypotension may

improve the outcome in patients with brain injury. The use of

hypertonic crystalloid solutions has also been proposed for

increasing plasma osmolality and decreasing cerebral edema.

N Engl J Med



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0 Colloid-based fluid-resuscitation strategies, including the use of

albumin, have similarly been based on physiological principles,

with the aim of maintaining or augmenting plasma oncotic

pressure to minimize extravasation of intravascular fluid into thebrain interstitium.

N Engl J Med



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0 Our study provides post hoc data to guide the choice of

resuscitation fluid in patients with traumatic brain injury, but the

biologic mechanisms for the observed differences in mortality

are unclear. Because there was no difference in hemodynamic-resuscitation end points or in the cause and time of death

between the two groups, one mechanism may be exacerbation of

vasogenic or cytotoxic cerebral edema induced by the

administration of albumin.

N Engl J Med



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0 In conclusion, in our study comparing albumin with saline for

intravascular fluid resuscitation in the ICU, higher mortality rates

were observed among patients with severe traumatic brain

injury who received 4% albumin than among those who receivedsaline. These findings suggest that saline is preferable to albumin

during the acute resuscitation of patients with severe traumatic

brain injury.

N Engl J Med



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Journal Reading SAFE - Emergency Medicine