Postoperative resuscitation with hypertonic saline or hyperoncotic albumin in patients following cardiac surgery: A review of the literature

Abstract

Background Over‐resuscitation in postcardiac surgery patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in hyperoncotic albumin and hypertonic saline for resuscitation in patients following cardiac surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in postcardiac surgical patients from the current literature. Methods A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications from 2009 to 2020. Results Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors, and had a lower positive fluid balance compared with patients receiving crystalloids. There was no difference in mortality in those given 20% albumin compared with crystalloids postcardiac surgery. Patients administered hypertonic saline following cardiac surgery had increased urinary output but its effect on total fluid and body weight was not significantly different compared with crystalloids. Conclusions In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients following cardiac surgery were reviewed. While there is data supporting the use of alternative fluid therapies in other critically ill populations, the limited literature focused on concentrated albumin and hypertonic saline for resuscitation following cardiac surgery is equivocal.

Expert consensus on the use of human serum albumin in adult cardiac surgery

“…Therefore, overresuscitation is relatively common in patients under-going cardiac surgery. [19,53] Recent studies have shown that volume overload is independently associated with an increased risk of morbidity (e. g., pulmonary edema, AKI, and congestive heart failure) and mortality in patients who undergo cardiac surgery. [54][55][56] As a colloid, HSA is believed to remain in the intravascular space for a more extended period and thus provide intravascular volume expansion more efficiently than crystalloids.…”

“…[63] In addition, HSA is also believed to help recovery of the endothelial glycocalyx, [20] which creates an osmotic gradient that promotes interstitial fluid to shift from the extravascular space to the intravascular space. [19,64,65] However, adding HSA to diuresis does not appear to help with the diuretic effect. [65,66] Notably, postoperative interstitial salt and water overload are usually more evident in high-risk patients with impaired heart function, a long pump run, or a complicated procedure.…”

“…HSA remains in the intravascular space for a more extended period than crystalloids when the endothelial glycocalyx is intact because of its large molecular weight. [ 19 , 20 ] With regard to the colloid oncotic effect of albumin, it is believed to provide intravascular volume expansion more sustainably and efficiently than crystalloids. Larger volumes of crystalloids are required to create similar changes in hemodynamic parameters during resuscitation compared with albumin.…”

“…Therefore, over-resuscitation is relatively common in patients undergoing cardiac surgery. [ 19 , 53 ] Recent studies have shown that volume overload is independently associated with an increased risk of morbidity (e.g., pulmonary edema, AKI, and congestive heart failure) and mortality in patients who undergo cardiac surgery. [ 54 – 56 ]…”

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

“…The majority of investigations for balanced versus normal saline crystalloid use come from mixed ICU populations, making their application to CT-ICU problematic [ 86 , 87 ]. Moreover, the use of albumin in continues to be controversial, with a mixed bag of results [ 88 ]. To date, the most significant positive results on prevention come from PrevAKI trials, where adherence to the Kidney Disease: Improving Global Outcomes (KDIGO) bundle reduced the rate of CSA-AKI in a single center RTC, and rate of moderate and severe AKI in a multicenter trial; the bundle consisted of avoidance of nephrotoxins, optimization of glycemic control, and optimization of volume status and hemodynamics [ 89 , 90 ].…”