What are the risks of using albumin (human albumin) as a colloid in pediatric craniotomy surgery?

Risks of Albumin Use in Pediatric Craniotomy Surgery

Albumin should be avoided in pediatric craniotomy surgery due to increased mortality risk in traumatic brain injury patients and lack of evidence supporting its use in pediatric neurosurgery, with isotonic crystalloids (0.9% saline) being the preferred first-line fluid. 1

Primary Mortality Risk in Brain-Injured Patients

• The SAFE study demonstrated a 62% increased relative risk of death (RR 1.62,95% CI 1.12-2.34) in patients with traumatic brain injury who received albumin compared to saline. 1
• This mortality signal was specific to brain injury patients, as those without traumatic brain injury showed no difference (RR 1.00,95% CI 0.56-1.79). 1
• A 2015 systematic review confirmed higher mortality in albumin-treated trauma patients (RR 1.35,95% CI 1.03-1.77), with the brain injury subgroup driving this effect. 1

Guideline Recommendations Against Albumin in Pediatric Neurosurgery

• The International Collaboration for Transfusion Medicine Guidelines (2024) specifically recommends against albumin in pediatric patients undergoing cardiovascular surgery for priming bypass circuits or volume replacement (Conditional Recommendation, Very Low Certainty of Evidence). 1
• The PeriOperative Quality Initiative (2024) recommends against routine albumin use in neurosurgery, stating that additional RCTs are needed to guide perioperative fluid therapy in this population. 1
• The Dutch Pediatric Society (2006) recommends isotonic saline as first-choice fluid for initial resuscitation in neonates and children with hypovolemia (Grade A recommendation). 1

Mechanism of Harm in Neurosurgical Patients

• Albumin can worsen cerebral edema through increased capillary leak in brain-injured patients, as the blood-brain barrier disruption allows albumin to leak into the interstitium, potentially amplifying cerebral edema. 1, 2
• The distribution of albumin across damaged capillary membranes reduces the oncotic pressure difference, making edema more likely rather than preventing it. 1
• French guidelines (2022) specifically note that in acute brain injury with focal neurological signs, albumin showed worse neurological prognosis in subarachnoid hemorrhage patients. 1

Coagulation Impairment Risks

• In small infants (3-15 kg), albumin 5% significantly impaired clot firmness on thromboelastography, though effects remained within normal range—less severe than hydroxyethyl starch but still clinically relevant. 3
• Standard coagulation tests (aPTT, PT) changed significantly after albumin administration in pediatric patients. 3
• This coagulation impairment is particularly concerning in craniotomy where hemostasis is critical.

Lack of Efficacy Evidence in Pediatric Populations

• No randomized controlled trials demonstrate benefit of albumin over crystalloids in pediatric neurosurgery or craniotomy specifically. 1
• The 2024 guidelines note that the role of albumin during major surgery needs further investigation, acknowledging the current evidence gap. 1
• In preterm neonates, albumin showed no benefit for volume replacement (RR for mortality 1.36,95% CI 0.69-2.66) with wide confidence intervals indicating underpowered studies. 1

Preferred Alternative: Isotonic Crystalloids

• Isotonic crystalloids (0.9% saline) are recommended as first-line therapy in acute brain injury to reduce mortality and improve neurological prognosis (GRADE 2+ recommendation). 1
• Isotonic solutions (280-310 mOsm/L) prevent cerebral edema risk, which is paramount in craniotomy patients. 1
• The volume ratio of albumin to saline needed for equivalent hemodynamic effect is only 1.4:1, making the theoretical volume advantage minimal. 1

Additional Safety Concerns

• Albumin carries risk of anaphylaxis, fluid overload (especially if infused >2 mL/min), hypotension, and hemodilution requiring RBC transfusion. 4
• Cost considerations are significant: albumin costs approximately $130 per 25g versus $1.50 per liter for isotonic saline, without proven superiority. 1, 4
• Preoperative hypoalbuminemia in craniotomy patients is a marker of illness severity and increased mortality risk (OR 1.91,95% CI 1.41-2.60), but should not be treated with albumin infusion. 4, 5

Clinical Algorithm for Fluid Management

• Use isotonic saline (0.9% NaCl) as first-line fluid for volume replacement in pediatric craniotomy. 1
• Administer initial bolus of 10-20 mL/kg, with repeated doses based on hemodynamic response. 1
• If large volumes are required and synthetic colloids are considered, recognize that even these carry risks—but albumin specifically should be avoided due to brain injury mortality signal. 1
• Monitor for fluid overload and maintain normovolemia rather than hypervolemia. 1

Critical Pitfall to Avoid

Do not administer albumin to "correct" a low preoperative albumin level in craniotomy patients—low albumin is a prognostic marker, not a treatment target, and albumin infusion does not improve outcomes while potentially increasing mortality in this population. 1, 4, 5