What is the role of albumin in cardiogenic shock?

From the Guidelines

Albumin should not be used as a first-line therapy in cardiogenic shock management, and its use should be considered only in selected cases where hypoalbuminemia is present alongside shock. In cardiogenic shock, where the heart cannot pump enough blood to meet the body's needs, albumin infusion (typically 5% or 25% solutions) may occasionally be used as part of volume resuscitation in patients who have hypoalbuminemia and are not responding to initial treatments. However, crystalloids like normal saline or lactated Ringer's solution are preferred for initial volume resuscitation. The primary benefit of albumin in this setting is its ability to maintain oncotic pressure within the vasculature, potentially helping to keep fluid in the intravascular space rather than leaking into tissues. This could theoretically improve cardiac preload without worsening pulmonary edema. The physiological rationale is that albumin, as a colloid, can increase intravascular volume more effectively than crystalloids per unit volume infused. However, evidence for albumin's benefit in cardiogenic shock specifically is weak, and its use should be considered only in selected cases where hypoalbuminemia is present alongside shock, as suggested by recent studies 1. Treatment of cardiogenic shock should primarily focus on addressing the underlying cause, supporting cardiac function with inotropes or vasopressors, and optimizing preload and afterload through other means, as recommended by recent guidelines 1. Some key points to consider in the management of cardiogenic shock include:

• Early recognition and intervention
• Hemodynamic monitoring and support
• Optimization of preload and afterload
• Use of inotropes and vasopressors as needed
• Consideration of mechanical support devices, such as intra-aortic balloon pumps or ventricular assist devices, in severe cases. It is essential to note that the management of cardiogenic shock should be individualized and based on the specific needs and circumstances of each patient, as highlighted in recent studies 1.

From the Research

Albumin Role in Cardiogenic Shock

• The role of albumin in cardiogenic shock is still being researched, with some studies suggesting its potential benefits in reducing mortality 2.
• A study published in 2022 found that early combination of albumin with crystalloid administration might reduce mortality in patients with cardiogenic shock 2.
• The study analyzed data from 1,332 patients who received crystalloid-only and 254 patients who received early albumin combination, and found that the albumin combination group had decreased 30-day and 60-day mortality 2.
• Another study published in 2021 discussed the management of cardiogenic shock, including the use of fluids, but did not specifically focus on the role of albumin 3.
• A 2014 study compared the use of colloids and crystalloids for fluid resuscitation in patients with shock, and found that mortality was not increased and probably decreased with the use of colloids 4.
• A 2021 study assessed the frequency of fluid responsiveness and outcomes of patients with cardiogenic shock receiving fluid resuscitation, but did not specifically examine the role of albumin 5.
• A 2018 systematic review compared the use of colloids and crystalloids for fluid resuscitation in critically ill patients, and found that using starches, dextrans, albumin or FFP, or gelatins versus crystalloids probably makes little or no difference to mortality 6.

Key Findings

• Early combination of albumin with crystalloid administration might reduce mortality in patients with cardiogenic shock 2.
• The use of colloids, including albumin, may be beneficial in certain patient populations, such as those with severe hypoalbuminemia 4.
• The role of albumin in cardiogenic shock is still being researched, and more studies are needed to fully understand its potential benefits and limitations 2, 3, 4, 5, 6.

Patient Populations

• Patients with cardiogenic shock who receive large volumes of crystalloids may benefit from the addition of albumin to their fluid resuscitation 2.
• Patients with severe hypoalbuminemia may benefit from the use of colloids, including albumin, for fluid resuscitation 4.
• Patients aged 60 years or older may benefit from early administration of albumin in combination with crystalloids for fluid resuscitation 2.