NUR-729 Fluid Resuscitation in Cardiac Surgery Assignment

Assignment Task

Background and the Problem

The perioperative management of cardiac surgery patients is associated with unique challenges. Hypotension is a conspicuous problem in the care of patients post-cardiac surgery. Volume expansion in response to hypotension is often required to optimize pre-load and/or improve cardiac output (Rabin et al., 2017). Fluid resuscitation is crucial for volume expansion, and crystalloids and colloids are used in practice. Although fluid resuscitation is so vital to the care of critically ill patients and the selection of resuscitative fluid is based on physiology, our clinical approach may be driven by physician preference to a great extent (Myburgh & Mythen, 2013). In cardiac surgery, intravenous fluid resuscitation is critical to ensure adequate intravascular volume, stroke volume, and tissue oxygen delivery, but preventing volume overload is also consequential (Vlasov et al., 2020).

HSA( Human serum albumin ), or plainly albumin for fluid resuscitation, has been ongoing in clinical practice for almost eight decades since its use in shock syndrome was first published in the 1940s (Buckley et al., 2021). Since then, it has been used widely in clinical practice despite the absence of established safety and efficacy in the literature (Buckley et al., 2021). The first prospective, randomized trial investigating albumin was not conducted until almost three decades after the initial published report. Since the initial prospective, randomized controlled trial, the efficacy of albumin for numerous clinical indications has been evaluated. Although albumin use in septic shock has not been shown to impact clinical outcomes and may not be advantageous over crystalloid use, it may warrant consideration for patients requiring continued large-volume fluid resuscitation efforts (Buckley et al., 2021).

Key Determinants of the Problem 

According to Moret et al. (2014), maintaining the vascular barrier competence, impeding interstitial edema, and protecting the microcirculation are crucial to achieving an optimal outcome in cardiopulmonary bypass surgery (CPB). Blood contact with roller pumps and foreign surfaces during CPB induces shear stress and a pressure drop across the pump boot, leading to transient systemic activation of the inflammatory and hemostatic systems (Moret et al., 2014). CPB is a particularly strong precipitant of vasoplegic syndrome, primarily due to its association with nitric oxide production and severe vasopressin deficiency (Shaefi et al., 2018). Moreover, patients after CPB often need volume resuscitation using the smallest possible amount of colloid solution because of fluid overload (Moret et al., 2014). For this purpose, human-derived albumin may be preferred over synthetic colloids because CPB priming with albumin preserves oncotic pressure, prevents platelet adhesion, and likely induces less consumption of coagulation factors. In patients with increased bleeding or renal failure, albumin is a safe alternative because of its minimal side effects (Moret et al., 2014).

Moreover, a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists (Aronson et al., 2017) revealed a practice variation among providers. The first choice of fluid for patients needing volume expansion during cardiopulmonary bypass (CPB ) without bleeding was crystalloids, whereas 5% albumin was the preferred first fluid choice for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most common adjunct colloid. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one-third preferred a mixture of 25% albumin and crystalloids (Aronson et al., 2017).

A recently published expert consensus on albumin uses in critically ill patients using the GRADE methodology to provide a reference for clinicians and clinical pharmacists on the use of albumin in clinical practice offers a grade 2+ weak recommendation for routine use of HSA for fluid resuscitation in perioperative shock after cardiac surgery (Yu et al., 2021). The study also grades the use of albumin and crystalloids in patients requiring fluid resuscitation in ECMO as an expert opinion considering there is no consensus on this matter and more studies may be necessary (Yu et al., 2021).

Impediment :

A significant impediment for healthcare facilities to use HSA clinically, along with the paucity of evidence, is the cost associated with using albumin. Total albumin expenditures significantly increased from $325 million to $468 million over five years among adult patients admitted to academic medical centers in the United States. In contrast, inappropriate albumin use has been reported to be as high as 90%, and the negative financial impact associated with unwarranted use remains a significant concern (Buckley et al., 2021). Our unit encounters similar obstacles with practice variations among providers using albumin and the cost associated with it without a clear guideline for albumin use. In our institution, AWP (Average Wholesale Price) for one bag of Albumin 5% (250mL) is $69.43. CT Surgery averages approximately 1000 doses yearly (~$70,000/year) per our pharmacy data.

Because albumin is progressively becoming a niche drug, refining the specific subpopulations of acutely ill patients who might benefit from its administration represents an essential nuance of an ongoing fluid debate. However, the results from the ALBICS trial indicate that further discussion is not required for at least one patient subpopulation and that one should avoid the routine use of albumin for patients undergoing cardiac surgery with cardiopulmonary bypass (Vlasov et al., 2020).

AIM and PICOT questions

Aim: The main objective is to underline the significance of the usage of guidelines for the use of albumin as an evidence-based practice and to get a positive patient outcome along with cost-saving benefits.

PICOT Question

In adult, post-cardiac surgery patients, can implementing guidelines restricting the use of albumin for fluid resuscitation, as opposed to no guidelines, decrease the use of albumin with potential cost-saving benefits and positive patient outcomes?

The PICOT question here is whether implementing an albumin-restrictive fluid resuscitation guideline in my practice will reduce the amount of albumin used due to a decrease in practice variation among providers in the setting of a practice guideline. Rabin et al. (2017) performed an interesting study as a retrospective analysis at the University of Maryland medical center between April 2014 and April 2015. This retrospective study analyzed albumin use in patients admitted to a post-cardiac surgery ICU. During the initial nine months of the study, there were no restrictions to albumin use. In January 2015, they initiated recommendations that restricted albumin 25% utilization up to a total dose of 25gm in patients with an obligatory volume requirement of more than 3000 ml crystalloid in the early post-operative period or patients with hypoalbuminemia and patients deemed as hypervolemic. Pharmacy records were compared for quality assurance. The study disclosed that there were 1401 patients enrolled over 13 months. They compared data on ventilator days, mortality, albumin usage, length of stay, and transfusion requirement in 961 patients before and 440 after the recommendations were instituted. After the protocols were created, there was a decrease in the trend of albumin utilization. The number of albumin doses reduced from 280 to a mean of 101 monthly doses (p<0>

Similarly, Fink et al. (2018) performed a retrospective interrupted time series data analysis on 192 patients in the CVICU after cardiac surgery, excluding heart transplants and mechanical circulatory devices. They used an "albumin-limited "strategy and lactated ringer-based fluid for resuscitation. They recommended utilizing albumin for refractory hypotension that was volume responsive with low filling pressures after up to 30 ml/kg of crystalloid replacement and in patients with increasing vasopressor requirement with low filling pressures. They found that the albumin reduction strategy had significant cost savings of approximately $30,549.20 over three months with no significant differences in patient outcomes regarding 30-day mortality benefit or length of stay. In addition, the time to extubation and weaning off pressors appears to be similar despite higher fluid balance in the albumin-limited group (Fink et al., 2018).

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