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Editor,—I disagree with the conclusions of Nadelet al that albumin should remain the first choice as a resuscitation fluid in sepsis.1
The objections have been fairly highlighted by the authors:
It is a blood product, which may carry an infection risk
Blood products are in constant short supply
It costs substantially more than starch without any proven benefit towards the final patient outcome but with added risks
Although albumin is relatively impermeable to the endothelial barrier under normal conditions, it leaks relatively easily into tissues of critically ill patients.2
Clearly trials are required to address this issue. Meanwhile, there is ample experimental and clinical evidence suggesting that hydroxyethyl starch (HES) of 250 kilodaltons size (pentastarch) is more effective than albumin in reducing capillary permeability oedema in experimental and clinical models of permeability oedema.3 In addition, it has been suggested that the molecular size of the 250 kD HES is optimal for use in capillary leak and sepsis.4 It works not only because of its oncotic pressure effects but may retain water in the circulation better by sealing endothelial gaps. The 250 kD HES has also been shown to have no adverse effect on clotting.5
Gelatins do not have the same virtues as HES as they have a short half life with rapid leak into interstitial space and have poor colloid osmotic function.
In our paediatric intensive care unit we stopped using albumin more than a year ago. Our standardised mortality (as well as Nadelet al’s) is lower than predicted. Does it follow that the choice of colloid has no influence on the survival of a critically ill child? If so, why use a product with so many potential drawbacks?