Hemorrhagic Shock
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Crystalloids should be considered the initial
resuscitation fluid of choice.
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Nonprotein colloids may be considered over
crystalloids when crystalloids (4 L) have failed to produce a response within
2 hours for adult patients.
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When nonprotein colloids are contraindicated*,
albumin 5 percent may be used.
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Patients who experience shock symptoms while
under-going hemodialysis are included in this guideline.
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Nonhemorrhagic (Maldistributive) Shock
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Crystalloids should be considered first-line
therapy for nonhemorrhagic shock. Clinical trials have not
shown colloids to be more effective in treating sepsis.
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In the presence of capillary leak with
pulmonary and/or severe peripheral edema, the administration of up to 4 L of
crystalloids in adults before using colloids is appropriate.
·
If nonprotein colloids are contraindicated*,
albumin may be given.
·
Nonprotein colloids and albumin should be used
with caution in patients with systemic sepsis.
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Hepatic Resection
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Crystalloid solutions should be used as
first-line therapy.
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If crystalloids have no effect, and anemia or
coagulopathy, or both, are present, then packed red blood cells or fresh
frozen plasma should be considered before albumin.
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Using albumin to maintain effective circulation
volume following major hepatic resection (greater than 40 percent) is
appropriate.
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Albumin is indicated when clinically important
edema develops secondary to crystalloid administration.
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Thermal Injury
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Fluid resuscitation should be initiated with
crystalloid solutions.
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If crystalloid resuscitation exceeds 4 L in
adults 18 to 26 hours postburn, and burns cover more than 30 percent of the
patient’s body surface area, nonprotein colloids may be added.
·
If nonprotein colloids are contraindicated*,
albumin may be used
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Cerebral Perfusion Pressure (CPP)
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Crystalloid administration should be the first
choice of treatment in maintaining CPP for treatment of vasospasm associated
with subarachnoid hemorrhage, cerebral ischemia, or head trauma.
Patients with elevated hematocrits should first receive crystalloids to
expand intravascular volume. Mannitol should be used to reduce intracranial
hypertension.
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If cerebral edema is a concern, albumin should
be used in concentrated form (25 percent) as a colloid to maintain CPP.
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If the hematocrit is less than 30, use packed
red blood cells to increase the intravascular volume and maintain CPP. If
volume therapy alone is ineffective, vasopressors may be needed
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Nutritional Intervention
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Albumin should not be used as a supplemental
source of protein calories in patients requiring nutritional intervention.
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Patients who cannot tolerate enteral feeding
may benefit from the administration of nonprotein colloids if all of the
following conditions are met:
1.
Serum albumin less than 2.0 g/dL
2.
Functioning gastrointestinal tract
3.
Failed short-chain peptide formulas
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Cardiac Surgery
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Crystalloids should be the fluid of choice as
the priming solution for cardiopulmonary bypass pumps.
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The use of nonprotein colloids in addition to
crystalloids may be preferable in cases in which it is extremely important to
avoid pulmonary shunting.
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For postoperative volume expansion,
crystalloids should be considered first-line therapy, followed by nonprotein
colloids, and finally albumin.
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Hyperbilirubinemia of the Newborn
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Albumin should not be administered in
conjunction with phototherapy.
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Albumin may be a useful adjuvant to exchange
transfusions when administered concurrently with blood transfusion but it
should not be used before transfusion.
·
Crystalloids and nonprotein colloids do not
have bilirubin binding properties and should not be considered as
alternatives to albumin.
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Cirrhosis and Paracentesis
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Diet modification (2 g sodium restriction/day)
in conjunction with diuretic therapy should be first-line therapy in adult
patients who have cirrhosis with ascites.
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When these fail or are not tolerated and
large-volume paracentesis (greater than 5 L) is needed, albumin (25 percent:
6 to 8 g/L removed) or nonprotein colloids should be considered the solution
of choice.
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Crystalloids should be considered as adjunctive
therapy in patients with cirrhosis when less than 3 L are removed and
repletion of intravascular volume is of concern.
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Using albumin alone to treat ascites without
large-volume paracentesis or to treat patients with noncirrhotic
postsinusoidal portal hypertension should be avoided.
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Nephrotic Syndrome
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Diuretic therapy alone is the treatment of
choice.
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If diuretic therapy fails, then short-term use
of 25 percent albumin in conjunction with diuretic therapy is appropriate for
patients with acute severe peripheral or pulmonary edema who have failed
diuretic therapy.
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Kidney and Liver Transplantation
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The effectiveness of albumin and nonprotein
colloids during and after renal transplantation surgery has not been
conclusively demonstrated.
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Because of excessive blood loss, volume
expanders such as crystalloids, blood products, nonprotein colloids, and
albumin may be required intraoperatively for liver transplants.
·
Albumin and nonprotein colloids may be useful
for postoperative liver transplant patients to control ascites and severe
pulmonary and peripheral edema.
·
Albumin may be used if the following conditions
are met:
1.
Serum albumin less than 2.5 g/dL
2.
Pulmonary capillary wedge pressure less than 12 mm Hg
3.
Hematocrit greater than 30 percent
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Plasmapheresis
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The use of albumin in conjunction with large
volume plasma exchange (greater than 20 mL/kg in one session, or greater than
20 mL/kg/week in repeated sessions) is appropriate.
·
Nonprotein colloids and crystalloids may be
substituted for some of the albumin in therapeutic plasmapheresis procedures
and should be considered cost-effective exchange mediums.
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Other Uses Considered Appropriate on the Basis of Limited Medical
Evidence and Results of the Consensus Exercise
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1.
Erythrocyte Sedimenting Agent
a. Granulocytapheresis
(nonprotein colloids): As a sedimenting solution for the collection of
granulocytes and for acute cytoreduction in leukemia with symptomatic
hyperleukocytosis.
b. Stem
cell separation (nonprotein colloids) for major ABO-incompatible bone marrow
transplantation.
2.
Cryopreservation
a. Cryopreservation
solutions for solid-organ transplant (albumin or nonprotein colloids).
b. Stem
cell cryopreservation (nonprotein colloids): As part of preservation
solutions for frozen storage of hematopoietic stem cells.
3.
Pretreatment of Dacron grafts before surgery and to
decrease bacterial adherence.
4.
Acute normovolemic hemodilution in surgery (nonprotein
colloid only appropriate).
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Other Uses Considered Inappropriate on the Basis of the Results of the
Consensus Exercise
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1.
Hypoalbuminemia
2.
Impending hepatorenal syndrome
3.
Increasing drug efficacy
4.
Acute pancreatitis
5.
Chronic pancreatitis
6.
Volume expansion in neonates, unless expansion with 10
mL/kg of crystalloids was unsuccessful
7.
Acute normovolemic hemodilution in surgery (albumin
inappropriate)
8.
Intradialytic blood pressure support
9.
Ovarian hyperstimulation syndrome
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