Question

• In children, is normal saline or albumin more effective in the treatment of hypotension?

Clinical Bottom Lines

1. Normal saline is as effective as albumin in the treatment of neonates with hypotension.
2. Albumin causes more weight gain than normal saline when given to hypotensive neonates.
3. Adults with hypotension, burns or hypoproteinemia who were given albumin had a higher mortality rate than those given normal saline or no treatment.

Summary of Key Evidence

1. Meta-analysis of mostly adult randomised controlled studies comparing albumin vs crystalloid for the treatment of hypotension, burns or hypoproteinemia.(1) In patients with hypotension, the relative risk of death with albumin treatment was 1.46 (95% CI 0.97-2.22).
2. A randomized study of NS vs 5% albumin in hypotensive preterm infants showed no difference in the rate of resolution of hypotension following 30cc/kg boluses.(2) However, in infants who required inotropic support, those treated with albumin required a larger volume of subsequent fluid (27cc/kg in the albumin group vs 10cc/kg in the NS group, p = 0.02). Infants who were treated with albumin had a larger weight gain at 48 hours.

Additional Comments

• There are several weaknesses to the meta-analysis as applied to pediatric patients:1) few pediatric studies - one hypotension, one burns, and two hypoalbuminemia; 2) the outcome measure was mortality, which was not the intent of the studie; and 3) different concentrations of albumin used in each study (4% - 20%).
• There are plausible biological mechanisms for harm from albumin: in cases of capillary leak, albumin also leaks out leading to more edema; impairs hemostasis via effects on platelets.
• Normal saline is less expensive than albumin (for 100cc NS costs $1.30, albumin costs $13.88) and has fewer side effects, such hypersensitivity reactions.

Citation

1. Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998; 317:235-40
2. So, KW et al. Randomised controlled trial of colloid or crystalloid in hypotensive preterm infants. Arch of Dis Child Fetal & Neonatal Ed 1997; 76(1): F43-46

CAT Author: Sarah Gelehrter, MD

CAT Appraisers: Robert Schumacher , MD

Date appraised: January 22, 2001