修回日期: 2024-07-22
接受日期: 2024-08-14
在线出版日期: 2024-08-28
血清白蛋白是调节血流动力和代谢的关键成分, 胃肠道手术围术期低白蛋白血症是预测术后并发症和预后的重要指标. 结合疾病状态、病理原因等因素, 人血白蛋白是成人胃肠道大手术或危重患者液体管理的重要选择, 对改善围术期安全性和预后可能具有突出的临床意义. 本文对血清白蛋白作为生物标记物预测疾病转归, 以及人血白蛋白辅助液体管理的相关研究进行综述, 旨在为胃肠外科围术期临床合理用药提供参考, 并探讨了包括提高研究质量、扩展研究内容等未来的相关研究方向.
核心提要: 回顾相关领域的最新研究进展, 归纳了围术期低白蛋白对胃肠外科手术预后的预测价值, 概述了合理应用外源性白蛋白可能有助于降低围术期风险, 并探讨了外源性白蛋白的临床使用方法和未来可能的相关研究方向.
引文著录: 贾祥浩, 高鑫鑫, 殷振华, 孔帅. 人血白蛋白在胃肠外科围手术期的合理应用. 世界华人消化杂志 2024; 32(8): 569-575
Revised: July 22, 2024
Accepted: August 14, 2024
Published online: August 28, 2024
Albumin plays a crucial role in the regulation of hemodyna-mics and metabolism. Perioperative hypoproteinemia in gastrointestinal surgery is an important predictor of postoperative complications and prognosis. Human serum albumin (HSA) can be considered as a valuable option for fluid management in adults who are undergoing major gastrointestinal surgery or critically ill, taking into account the disease state, pathologic causes, and other relevant factors. HSA may play a crucial role in enhancing perioperative safety and patient prognosis. This paper reviews the application of albumin as a biomarker for predication and HSA as an aid to fluid management, with an aim to provide suggestions for the rational use of human serum albumin in the perioperative period of gastrointestinal surgery.
- Citation: Jia XH, Gao XX, Yin ZH, Kong S. Rational application of human serum albumin in perioperational period of gastrointestinal surgery. Shijie Huaren Xiaohua Zazhi 2024; 32(8): 569-575
- URL: https://www.wjgnet.com/1009-3079/full/v32/i8/569.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v32.i8.569
当前, 胃肠外科手术并发症和死亡总体相对较少, 但约15%的患者处于高风险状态[1]. 影响围术期风险的因素很多, 其中血清白蛋白(albumin, Alb)水平降低与疾病本身及相关器官的功能状态有关[2]. 一项大型荟萃分析发现, 急症患者Alb每下降10 g/L, 并发症整体和全因死亡率分别增加89%和137%[3]. SAFE试验的事后分析报告, 包括大量术后入住ICU的患者在内, 基线Alb≤25 g/L与死亡风险独立相关[4]. 而大型回顾性研究报告, 术前Alb每增加1 g/L, 结-直肠术后并发症和死亡率分别减少8.7%和17.7%[5], 因此Alb可用于预测患者预后. 通过提升Alb并恢复体液平衡, 可能成为改善此类患者的围术期管理、降低手术风险的重要措施.
Alb是血浆中含量最高的蛋白质成分, 浓度约35-50 g/L, 其作用除了维持胶体渗透压、储存并转运体内代谢物和药物之外, 还可抑制氧化应激、维护毛细血管完整性及改善微循环[6,7]. Alb参与血管内皮糖萼层的构成, Alb降低及液体疗法均可能会损害内皮糖萼层结构并导致该层脱落, 影响内皮功能[8]. 人血白蛋白(human serum albumin, HSA)是胃肠外科围术期的常用药物之一, 不仅具有能够提升Alb浓度、改善血流动力学、减轻组织水肿等胶体功能, 还可能具有保护和恢复内皮糖萼层、降低毛细血管通透性、调节炎症反应和氧化应激等功能[8], 进而加速患者康复. 本文对Alb和HSA在成人胃肠道围术期的临床研究进行综述, 供临床实践和相关研究参考.
对胃肠道择期手术患者的回顾性分析显示, 术前Alb≤40 g/L可预测再次手术的风险, ≤38 g/L可预测尿路感染[9], <30 g/L与ICU及住院期间全因死亡率有关[10]. 对胃肠道恶性肿瘤等限期手术的患者, 术前Alb<32 g/L仍然是术后总体并发症、感染性或非感染性并发症以及死亡率的重要预测指标[11]. 这些研究均提示, 术前Alb水平与胃肠道手术并发症、术后住院时长及死亡率等呈负相关.
胃肠吻合口瘘作为常见的术后并发症, 其发生与术前Alb降低、吻合口水肿、缺血坏死或感染有关[12]. 接受回肠储袋肛管吻合术的患者, 术前Alb<35 g/L是吻合口漏的独立预测因子[13]. 肠梗阻是另一种胃肠道术后常见并发症, 术前Alb每升高一个标准差则术后肠梗阻风险可降低27%, 与Alb<39.2 g/L相比, Alb≥39.2 g/L患者相关风险可降低57%[14].
对接受腹腔镜胃切除术的患者, 术前Alb<35 g/L是术后Clavien-Dindo Ⅱ级或以上术后并发症的独立风险因素[15], 而术前Alb水平较高是减重手术患者术后30 d内再次入院的唯一保护性因素[16]. 即使对于门诊手术患者, 术前Alb<35 g/L也与发生主要并发症及死亡相关[17].
其他回顾性研究表明, 腹部大手术危重患者术后急性肾损伤(acute kidney injury, AKI)发生率约28.9%, 术后即刻Alb<32 g/L可明显增加AKI的发生风险[18], 且术后Alb降低还是此类患者机械通气撤机失败的危险因素[19]. 另外, Alb在术后第1 d降低与胰瘘的发生显著相关, 是胰十二指肠切除术(pancreaticoduodenectomy, PD)患者术后发生胰瘘的独立预测因素[20].
ΔAlb定义为手术前后Alb浓度的差异, 其绝对值以g/L表示, 相对值以百分数表示, 后者常用的计算公式为: (术前Alb－术后当天Alb)/术前Alb×100%[21]. 与术前或术后Alb浓度不同, ΔAlb更有利于提供手术应激反应相关的动态信息. 但手术期间Alb降低的机制尚不清楚, 可能受到多重因素的动态影响, 包括大量输液、毛细血管渗漏增加和Alb代谢状态的变化等[22].
患者接受急诊剖腹探查时, ΔAlb平均高达4.8 g/L, 其升高与发生术后并发症显著相关, 切口开裂和渗漏是最常见的并发症, 其他还包括急性呼吸窘迫综合征、AKI及吻合口漏等[23]. 对腹部大手术患者, ΔAlb≥10 g/L与术后并发症总体风险增加3倍相关, 可用于识别易出现术后并发症的高危患者[24].
ΔAlb相对值达到14.0%或19.0%, 可用于识别胃癌切除术后短期并发症高风险的患者[21,25]. 结-直肠手术的患者, ΔAlb≥15%则术后感染等主要并发症会恶化, 住院时长也相应延长[26]. ΔAlb每增加5%, PD术后并发胰瘘的风险增加83%, 是胰瘘强有力的独立预测因子[27]. 对接受腹腔镜肠切除术的患者, 围术期4 d内ΔAlb达到24%可能为术后并发症的独立预测指标[28].
相关荟萃分析表明, ΔAlb用于预测胃肠道术后并发症的敏感性在63%-84%之间, 而特异性在61%-86%之间, 其临界值范围介于5-11 g/L或14%-27%之间[29].
综上所述, Alb降低很可能与胃肠道围术期并发症风险增加相关, 并存在相应的发生和发展过程, 尽管具体的切点值存在差异, 但术前、术后Alb降低或Δalb升高都可定性预测患者的术后转归, 有利于及早对患者进行风险分层管理和指导选择手术时机等, 对某些接受创伤较小或门诊手术的患者可能也同样有效.
在腹部大手术并发症风险较高的患者中, RELIEF研究发现限制性与开放性液体疗法相比, 前者不仅未提高术后1年无残疾存活率, 还增加了AKI的发生[30]. 另一方面, 术中经食道多普勒监测下的输液方案, 可缩短进行结-直肠切除术患者的住院时长, 并减少并发症[31]. 对此, 加速康复外科协会(enhanced recovery after surgery, ERAS)提出围术期液体治疗的目标是维持液体稳态, 避免液体过多和器官灌注不足, 首选围术期接近零的液体平衡策略, 并根据实际需要确定是否启用目标导向液体治疗(goal-directed fluid therapy, GDFT), 尤其是高危患者和接受可导致血容量大量丢失(包括失血和蛋白质/体液转移)的手术患者[32].
OPTIMISE研究发现, 在腹部大手术患者中, 与对照组比较, GDFT组的术后并发症和死亡率有降低的趋势(P = 0.07), 荟萃分析还表明GDFT可减少术后感染以及住院时间[33]. FEDORA试验结果显示, 中低风险患者接受包括腹部在内的中等风险手术后, GDFT组AKI、肺水肿、切口感染等并发症明显减少, 住院时间更短[34]. 接受结-直肠手术的患者, 术中GDFT可减少并发症、加快胃肠道功能恢复[35]. 上述研究均表明, GDFT对于胃肠道等腹部手术的患者, 是一项安全有效的围术期液体管理策略.
分析接受腹部手术高危患者的治疗及效果, 结果虽然GDFT组术中和术后出血更多、术中晶体液输入更多, 但术后肺水肿[36]和腹腔积液的发生率[37]显著低于常规治疗组. 这表明, GDFT策略在改善围术期液体管理的同时, 并不意味着围术期液体输入量较传统策略一定会减少, 有可能会更多, 而这可能是不利的, 因为另有研究表明, 患者在PD术中液体输入的增多与围术期预后较差有关, 特别是术前Alb≤30 g/L的患者可能对容量超负荷特别敏感[38], 而液体输入过量会加重Alb的稀释.
POWER研究事后分析表明, 遵循ERAS策略的结-直肠术后AKI发病率为7.7%, 对此唯一可改变的独立风险因素是术前Alb<35 g/L[39]. 对接受食管和胰腺手术的患者, 在围术期72 h内重复测量Alb, 发现手术初期阶段Alb即快速下降, 截至术后1 h Alb累计转移24 g, 这可能主要由输液过量和毛细血管渗漏共同造成[22], 因此Alb的变化显然与手术类型和液体管理均密切相关. 并且, 在术前Alb基本正常的结-直肠手术患者中, 即使联合应用腹腔镜技术和ERAS方案, 出现感染及吻合口漏组的平均ΔAlb达到5 g/L, 显著高于未出现感染性并发症组的2 g/L[40]. 因此, 在手术操作技术和GDFT液体管理策略之外, 仍需考虑提升Alb水平. 这实际上遵循了ERAS理念, 因为ERAS要求在具体的实施过程中应进行个体化处理[41]. SAFE研究早先已证实4% HSA可以显著减少ICU患者复苏时的输液量[42], 最新研究则发现在PD患者中联合使用4% HSA, 与限制性输液策略比较, GDFT策略对液体总量及HSA的用量均更少, 且术后严重并发症更少、住院时间更短[43], 进一步表明GDFT辅以HSA的治疗策略, 在有效管理体液超负荷风险的同时, 可能会产生更好的疗效.
与限制性输液策略比较, 开放式和GDFT输液策略都可能输注更多的液体, 但这两种策略对相关并发症的影响显著不同[44], 至少部分原因在于胃肠外科围术期的液体管理效果, 还受到液体种类和输液时间等因素的影响[45]. 由于晶体液比胶体液更容易透过血管内皮进入组织间隙, 这可能会加重组织水肿并损害氧合, 但胶体在血管内的停留时间更长, 可更好地维持血流动力学稳定, 这反过来可能会改善组织灌注和氧合[46]. 对外科患者, 当输注的晶体液超过3-4 L且仍需要扩容支持, 却不需要输注血液制品时, 可能需要改用胶体[47].
荟萃分析发现, 即使都采用了GDFT策略, 比较合成类胶体与晶体液, 患者死亡率、术后并发症等表现均相似, 没有任何优势[48]. 对于危重症患者, 与晶体液组比较, 尽管胶体液组平均动脉压明显升高, 且液体总量明显减少, 但羟乙基淀粉亚组的全因和90 d死亡率却显著升高, 而HSA亚组的心脏指数改善最显著, 表明输注HSA可能更有效地改善了血流动力学[49]. 结合上述研究, 合成类胶体不能改善切口或其他部位组织的供氧[50], 而HSA则可能不仅改善血流动力学, 还改善了组织灌注与氧合. 与输注生理盐水比较, HSA不仅在显著减少液体用量的同时提升平均动脉压[42], 而且对基线Alb≤25 g/L的患者扩容效应可能更显著[51]. 研究还表明[17], 术前Alb浓度每提升1 g/L, 手术患者的主要并发症风险将减少6%, 进一步表明输注HSA是潜在的有效干预途径.
研究表明, 对于Alb水平<30 g/L的危重症患者, 给予20% HSA可将平均液体输入量降为对照组的1/3, 并更好地改善呼吸、循环和中枢神经等系统的功能[52]. ALBIOS研究的干预目标是提升危重症患者Alb至≥30 g/L, 而非扩容, 即便如此, 与4% HSA比较, 仍观察到20% HSA在减少输液量的同时更快地改善了血流动力学[53]. 其他研究还表明, 输注20% HSA溶液100 mL, 其血流动力学效应与输注4% HSA溶液500 mL相当, 但输入的液体量、钠和氯均显著减少[54], 患者存活率也更高[55]. 考虑到胃肠道大手术往往会迅速降低Alb[56], 当患者需要输液以稳定循环但又出现液体超负荷迹象时, 应考虑使用20% HSA治疗[57], 同时兼顾扩容和纠正低白蛋白血症的目标, 且Alb应提升至30 g/L及以上的水平.
另外, 分别对健康志愿者和腹部大手术后第1 d的患者输注20% HSA, 观察近2 h的扩容效果, 两组之间HSA动力学效应没有显著差异[58], 扩容半衰期中位时长分别为7.6 h和10.3 h[59], 提示20% HSA可能尤其适合需要持久扩容的腹部大手术患者.
创伤性脑损伤可能是4% HSA的外科禁忌症, 其治疗结局比生理盐水差[60], 但这可能与HSA本身无关, 更可能与制剂的低渗性有关, 因为一项2022年的荟萃分析提示, 在创伤性脑损伤患者中, 与脑灌注压靶向治疗比较, 基于Lund指南应用20%-25%的HSA与死亡率显着降低相关(14.5% vs 38.1%; P = 0.002)[61]. 对此可能的一种解释是, 输注等渗胶体液不能逆转患者已经出现的间质性水肿, 在某些情况下可能比晶体液诱发的组织水肿更严重, 因为低蛋白血症会导致血管内皮糖萼层消失[62]. 据此, 对于合并创伤性脑损伤的胃肠外科患者, 必要时应考虑输注高浓度HSA.
有研究表明术后无论以5%、20%或25%溶液的形式给药, 50 g白蛋白都会使血浆体积增加500 mL[63]. 一项随机化试验在腹部大手术术后出现灌注不足的患者中, 比较了5% HSA在不同输注速度下的扩容效果, 剂量均为10 mL/kg(理想体重), 结果发现从输注开始到180 min, 快速输注组(30 min输注完毕)与慢速输注组(180 min输注完毕)的扩容效果基本相同, 但慢速输注组扩容效率显著降低[64]. 这一结果表明, 尽管相同单位剂量的HSA对腹部大手术患者的扩容效果没有显著差异, 但快速输注HAS对需要快速扩容的患者可能是更好的选择. 另一项随机化试验在膀胱切除术大出血阶段, 分别以12 mL/kg或3 mL/kg(均为理想体重)的剂量输注5% HSA或20% HSA, 30 min输注完毕, 结果表明不同浓度HSA均有显著的扩容效果, 在中位出血848 mL的情况下, 按照这个方案输注白蛋白血容量变化仅为+63 mL和-44 mL, 且作用可持续5 h以上[65]. 结合这几项研究可以看出, 根据需要在腹部大手术术中或术后快速输注不同浓度HSA, 都可以产生显著且持久的扩容效果. 按照液体丢失量合理使用白蛋白, 有利于实现围术期维持液体平衡的液体管理目标, 这对于其他围术期患者群体有一定的参考价值. 但由于以上研究均未集中于胃肠外科领域, 且结果尚未得到充分验证, 应注意到临床环境的内在异质性.
除胶体功能之外, HSA还具有多重生物学活性, 包括与血红素、酶类、炎性介质及抗生素等多种物质结合, 参与并稳定相关代谢途径; 清除血红素铁、抑制脂质过氧化以及储存与转换一氧化氮, 防止氧化应激损害; 还可结合与稳定血栓素A2, 参与前列腺素的合成和清除, 调节、控制炎症反应[6]. 另外, HSA可促进细胞产生和利用鞘氨醇磷酸盐, 并减缓内皮细胞表面糖萼的丢失, 有助于稳定细胞结构、抑制细胞特异性凋亡[6,7], 进而改善创伤、炎症等状态下的微血管渗透性. 与之相关的探索性临床研究提示, 输注HSA可能有助于改善脓毒症休克患者的血管内皮功能, 此效应可持续4 h以上[66].
综上所述, 当胃肠道大手术患者处于血流动力不稳定、脓毒症或器官功能障碍等状态时, 使用HSA的潜在获益可能远大于风险[2]. 2021年国内专家共识建议, 对腹部围术期危重症患者应严格监测Alb水平, <30 g/L可作为Alb降低的切点, 干预目标为确保Alb≥30 g/L[67]. 需要注意的是, 部分患者输注HSA后会出现过敏、水肿或液体超负荷等不良反应, 其发生率与输注量、输注速度及患者个体状况相关, 在减慢输注速度或停止输注后, 此类不良反应通常会消退, 少数患者需要对症、支持处理.
众所周知, Alb降低往往不是独立的疾病, 更经常以原发病或损伤的并发症形式出现, 输注HSA的临床试验容易受到多种因素的干扰, 这对试验结果的分析与判断带来不利影响. 最近, 国际输血医学指南协作组织(The International Collaboration for Transfusion Medicine Guidelines, ICTMG)发布了一份临床应用HSA的国际指南, 在危重症、心血管手术、肝硬化并发症等领域提出多项临床建议, 但强调由于相关随机对照试验很少或相互冲突, 绝大多数建议只能建立在低质量或极低质量证据的基础上, 这一现状充分凸显了开展高质量研究的必要性[68].
除此之外, HSA相关研究还存在实用性不足的局限, 表现为当前的研究由于缺乏可比较的剂量策略等因素, 不同浓度HSA制剂的选择、各自适应症及其合理剂量、液体超负荷的风险处理和给药时机等诸多问题都不确定, 而这些问题在临床实践中却具有重要意义. 其中, 聚焦于胃肠外科围术期应用HSA的实用性研究尤其缺乏, 其紧迫性也格外突出. 例如, 研究发现在合并低白蛋白血症的患者中, 术前补充20%的HSA可以降低AKI的发生率[69], 但是针对胃肠外科手术的相关研究少见, 较难给临床提供直接证据支持.
值得注意的是, 随着近年来研究的进展, 已发现循环中Alb的含量并不能完全代表其自身的生理功能,对此提出了"有效白蛋白浓度"的概念, 这强调了要关注在结构和功能上均完好无损的白蛋白含量[70]. 通过半胱氨酸残基-34携带的具有氧化还原活性的巯基(-SH)捕获自由基和实现抗氧化特性, 对于结构正常的Alb非胶体功能具有关键作用. 但在以全身炎症反应和氧化应激增强为特征的病理条件下, Alb的结构和功能会发生障碍, 这种障碍对疾病本身的影响却所知有限[70]. 在此背景下, 对临床研究中输注外源性HSA所带来的"有效白蛋白浓度"提升及其获益情况, 显然难以清晰了解, 这可能也是引起相关试验结果冲突的潜在原因之一. 这一概念还提示, 外源性HSA输入量不能直接等量为天然Alb的增加量, 在未来分析相关的剂量-效应研究中需加以考虑.
因此, 未来开展胃肠外科围术期应用HSA的研究, 不仅需要从试验的设计、执行和分析的角度提高研究质量, 还需要在HSA对血流动力学、尿量和实验室检查的传统影响之外进一步扩展研究内容, 包括基于疾病或手术分层如何选择最佳的剂型和剂量策略, 合理化用药时机以及对不良反应的预测与处理等问题. 从分子结构的层面厘清不同临床过程中白蛋白的功能变化, 将对揭示输注外源性HSA的潜在获益建立更加坚实的基础.
Alb降低是胃肠外科围术期患者常见的临床表现, 可用于预测相关高危人群术后并发症及整体预后. HSA不仅可以有效地扩充血容量、改善血流动力学, 还可以调节炎症反应、维护微循环功能, 以多种方式减缓重要器官损伤及相关并发症, 是成人围术期GDFT液体管理策略的主要辅助用药选择之一, 在改善胃肠道大手术或高危患者的康复过程中, 总体显示出降低围术期风险的潜在价值. 未来的胃肠道围术期液体疗法相关研究应当注意提升研究质量、明确HSA的最佳应用条件、剂量和治疗时机等临床重点事项, 并深入探索白蛋白分子结构与疾病或损伤的病理生理学之间的复杂关联, 以便在确保患者安全的基础上, 充分发挥其治疗潜力.
武田国际贸易有限公司为本文发表提供了科学的审校支持.
学科分类: 胃肠病学和肝病学
手稿来源地: 山东省
同行评议报告学术质量分类
A级 (优秀): 0
B级 (非常好): B, B
C级 (良好): C
D级 (一般): 0
E级 (差): 0
科学编辑:张砚梁 制作编辑:张砚梁
| 1. | Jakobson T, Karjagin J, Vipp L, Padar M, Parik AH, Starkopf L, Kern H, Tammik O, Starkopf J. Postoperative complications and mortality after major gastrointestinal surgery. Medicina (Kaunas). 2014;50:111-117. [PubMed] [DOI] |
| 2. | Neel DR, McClave S, Martindale R. Hypoalbuminaemia in the perioperative period: clinical significance and management options. Best Pract Res Clin Anaesthesiol. 2011;25:395-400. [PubMed] [DOI] |
| 3. | Vincent JL, Dubois MJ, Navickis RJ, Wilkes MM. Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials. Ann Surg. 2003;237:319-334. [PubMed] [DOI] |
| 4. | SAFE Study Investigators, Finfer S, Bellomo R, McEvoy S, Lo SK, Myburgh J, Neal B, Norton R. Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study. BMJ. 2006;333:1044. [PubMed] [DOI] |
| 5. | Chiang JM, Chang CJ, Jiang SF, Yeh CY, You JF, Hsieh PS, Huang HY. Pre-operative serum albumin level substantially predicts post-operative morbidity and mortality among patients with colorectal cancer who undergo elective colectomy. Eur J Cancer Care (Engl). 2017;26. [PubMed] [DOI] |
| 6. | Farag E, Ebrahim ZY. The Perioperative Use of Albumin. Perioperative Fluid Management. 2016;215-234. [DOI] |
| 7. | Rozga J, Piątek T, Małkowski P. Human albumin: old, new, and emerging applications. Ann Transplant. 2013;18:205-217. [PubMed] [DOI] |
| 8. | Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin. 2020;36:1961-1973. [PubMed] [DOI] |
| 9. | Czempik PF, Czepczor K, Czok MZ. Should we change reference range for serum albumin in major gastrointestinal surgery? Preoperative serum albumin as an important prognostic factor. J Perioper Pract. 2020;30:271-276. [PubMed] [DOI] |
| 10. | Jin X, Li J, Sun L, Zhang J, Gao Y, Li R, Ren J, Hou Y, Su D, Liu J, Wang X, Chen D, Wang G, Wiedermann CJ. Prognostic Value of Serum Albumin Level in Critically Ill Patients: Observational Data From Large Intensive Care Unit Databases. Front Nutr. 2022;9:770674. [PubMed] [DOI] |
| 11. | Lin MY, Liu WY, Tolan AM, Aboulian A, Petrie BA, Stabile BE. Preoperative serum albumin but not prealbumin is an excellent predictor of postoperative complications and mortality in patients with gastrointestinal cancer. Am Surg. 2011;77:1286-1289. [PubMed] |
| 13. | Nisar PJ, Appau KA, Remzi FH, Kiran RP. Preoperative hypoalbuminemia is associated with adverse outcomes after ileoanal pouch surgery. Inflamm Bowel Dis. 2012;18:1034-1041. [PubMed] [DOI] |
| 14. | Liang WQ, Zhang KC, Li H, Cui JX, Xi HQ, Li JY, Cai AZ, Liu YH, Zhang W, Zhang L, Wei B, Chen L. Preoperative albumin levels predict prolonged postoperative ileus in gastrointestinal surgery. World J Gastroenterol. 2020;26:1185-1196. [PubMed] [DOI] |
| 15. | Chen WZ, Chen XY, Zhang FM, Dong QT, Ji YB, Chen XL, Zhuang CL, Chen XX. Effect of nutritional risk on short-term outcomes after laparoscopic-assisted gastrectomy: a prospective study from two centers. Eur J Gastroenterol Hepatol. 2018;30:136-142. [PubMed] [DOI] |
| 16. | Khorgami Z, Andalib A, Aminian A, Kroh MD, Schauer PR, Brethauer SA. Predictors of readmission after laparoscopic gastric bypass and sleeve gastrectomy: a comparative analysis of ACS-NSQIP database. Surg Endosc. 2016;30:2342-2350. [PubMed] [DOI] |
| 17. | Curran S, Apruzzese P, Kendall MC, De Oliveira G. The impact of hypoalbuminemia on postoperative outcomes after outpatient surgery: a national analysis of the NSQIP database. Can J Anaesth. 2022;69:1099-1106. [PubMed] [DOI] |
| 19. | Li S, An YZ, Ren JY, Zhu FX, Chen H. Myocardial injury after surgery is a risk factor for weaning failure from mechanical ventilation in critical patients undergoing major abdominal surgery. PLoS One. 2014;9:e113410. [PubMed] [DOI] |
| 20. | Fujiwara Y, Shiba H, Shirai Y, Iwase R, Haruki K, Furukawa K, Futagawa Y, Misawa T, Yanaga K. Perioperative serum albumin correlates with postoperative pancreatic fistula after pancreaticoduodenectomy. Anticancer Res. 2015;35:499-503. [PubMed] |
| 21. | Ai S, Sun F, Liu Z, Yang Z, Wang J, Zhu Z, Du S, Guan W. Change in serum albumin level predicts short-term complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer. ANZ J Surg. 2019;89:E297-E301. [PubMed] [DOI] |
| 22. | Norberg Å, Rooyackers O, Segersvärd R, Wernerman J. Leakage of albumin in major abdominal surgery. Crit Care. 2016;20:113. [PubMed] [DOI] |
| 23. | Kumar D M, Sivakumar S. Evaluation of the role of pre-operative albumin and its post-operative drop in the prediction of outcomes of emergency laparotomy. International Surgery Journal. 2020;7. [DOI] |
| 24. | Labgaa I, Joliat GR, Kefleyesus A, Mantziari S, Schäfer M, Demartines N, Hübner M. Is postoperative decrease of serum albumin an early predictor of complications after major abdominal surgery? A prospective cohort study in a European centre. BMJ Open. 2017;7:e013966. [PubMed] [DOI] |
| 25. | Liu ZJ, Ge XL, Ai SC, Wang HK, Sun F, Chen L, Guan WX. Postoperative decrease of serum albumin predicts short-term complications in patients undergoing gastric cancer resection. World J Gastroenterol. 2017;23:4978-4985. [PubMed] [DOI] |
| 26. | Ge X, Dai X, Ding C, Tian H, Yang J, Gong J, Zhu W, Li N, Li J. Early Postoperative Decrease of Serum Albumin Predicts Surgical Outcome in Patients Undergoing Colorectal Resection. Dis Colon Rectum. 2017;60:326-334. [PubMed] [DOI] |
| 27. | Shen J, Guo F, Sun Y, Zhao J, Hu J, Ke Z, Zhang Y, Jin X, Wu H. Predictive nomogram for postoperative pancreatic fistula following pancreaticoduodenectomy: a retrospective study. BMC Cancer. 2021;21:550. [PubMed] [DOI] |
| 28. | Müller C, Stift A, Argeny S, Bergmann M, Gnant M, Marolt S, Unger L, Riss S. Delta albumin is a better prognostic marker for complications following laparoscopic intestinal resection for Crohn's disease than albumin alone - A retrospective cohort study. PLoS One. 2018;13:e0206911. [PubMed] [DOI] |
| 29. | Joliat GR, Schoor A, Schäfer M, Demartines N, Hübner M, Labgaa I. Postoperative decrease of albumin (ΔAlb) as early predictor of complications after gastrointestinal surgery: a systematic review. Perioper Med (Lond). 2022;11:7. [PubMed] [DOI] |
| 30. | Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, Christophi C, Leslie K, McGuinness S, Parke R, Serpell J, Chan MTV, Painter T, McCluskey S, Minto G, Wallace S; Australian and New Zealand College of Anaesthetists Clinical Trials Network and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med. 2018;378:2263-2274. [PubMed] [DOI] |
| 31. | Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069-1076. [PubMed] [DOI] |
| 32. | Feldheiser A, Aziz O, Baldini G, Cox BP, Fearon KC, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2016;60:289-334. [PubMed] [DOI] |
| 33. | Pearse RM, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, Grocott MP, Ahern A, Griggs K, Scott R, Hinds C, Rowan K; OPTIMISE Study Group. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311:2181-2190. [PubMed] [DOI] |
| 34. | Calvo-Vecino JM, Ripollés-Melchor J, Mythen MG, Casans-Francés R, Balik A, Artacho JP, Martínez-Hurtado E, Serrano Romero A, Fernández Pérez C, Asuero de Lis S; FEDORA Trial Investigators Group. Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial). Br J Anaesth. 2018;120:734-744. [PubMed] [DOI] |
| 35. | Xu C, Peng J, Liu S, Huang Y, Guo X, Xiao H, Qi D. Goal-directed fluid therapy versus conventional fluid therapy in colorectal surgery: A meta analysis of randomized controlled trials. Int J Surg. 2018;56:264-273. [PubMed] [DOI] |
| 36. | de Waal EEC, Frank M, Scheeren TWL, Kaufmann T, de Korte-de Boer D, Cox B, van Kuijk SMJ, Montenij LM, Buhre W. Perioperative goal-directed therapy in high-risk abdominal surgery. A multicenter randomized controlled superiority trial. J Clin Anesth. 2021;75:110506. [PubMed] [DOI] |
| 37. | Peltoniemi P, Lehto I, Pere P, Mustonen H, Lehtimäki T, Seppänen H. Goal-directed fluid management associates with fewer postoperative fluid collections in pancreatoduodenectomy patients. Pancreatology. 2023;23:456-464. [PubMed] [DOI] |
| 38. | Eng OS, Goswami J, Moore D, Chen C, Gannon CJ, August DA, Carpizo DR. Intraoperative fluid administration is associated with perioperative outcomes in pancreaticoduodenectomy: a single center retrospective analysis. J Surg Oncol. 2013;108:242-247. [PubMed] [DOI] |
| 39. | Zorrilla-Vaca A, Mena GE, Ripolles-Melchor J, Lorente JV, Ramirez-Rodriguez JJM, Grant MC. Risk factors for acute kidney injury in an enhanced recovery pathway for colorectal surgery. Surg Today. 2021;51:537-544. [PubMed] [DOI] |
| 40. | Wierdak M, Pisarska M, Kuśnierz-Cabala B, Witowski J, Dworak J, Major P, Małczak P, Ceranowicz P, Budzyński A, Pędziwiatr M. Changes in plasma albumin levels in early detection of infectious complications after laparoscopic colorectal cancer surgery with ERAS protocol. Surg Endosc. 2018;32:3225-3233. [PubMed] [DOI] |
| 42. | Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247-2256. [PubMed] [DOI] |
| 43. | Peltoniemi P, Pere P, Mustonen H, Seppänen H. Optimal Perioperative Fluid Therapy Associates with Fewer Complications After Pancreaticoduodenectomy. J Gastrointest Surg. 2023;27:67-77. [PubMed] [DOI] |
| 44. | Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114:640-651. [PubMed] [DOI] |
| 46. | Kimberger O, Arnberger M, Brandt S, Plock J, Sigurdsson GH, Kurz A, Hiltebrand L. Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology. 2009;110:496-504. [PubMed] [DOI] |
| 47. | Haskins IN, Baginsky M, Amdur RL, Agarwal S. Preoperative hypoalbuminemia is associated with worse outcomes in colon cancer patients. Clin Nutr. 2017;36:1333-1338. [PubMed] [DOI] |
| 48. | Tyagi A, Maitra S, Bhattacharjee S. Comparison of colloid and crystalloid using goal-directed fluid therapy protocol in non-cardiac surgery: a meta-analysis of randomized controlled trials. J Anesth. 2020;34:865-875. [PubMed] [DOI] |
| 49. | Martin GS, Bassett P. Crystalloids vs. colloids for fluid resuscitation in the Intensive Care Unit: A systematic review and meta-analysis. J Crit Care. 2019;50:144-154. [PubMed] [DOI] |
| 50. | Reiterer C, Kabon B, Zotti O, Obradovic M, Kurz A, Fleischmann E. Effect of goal-directed crystalloid- versus colloid-based fluid strategy on tissue oxygen tension: a randomised controlled trial. Br J Anaesth. 2019;123:768-776. [PubMed] [DOI] |
| 51. | Wiedermann CJ. Moderator Effect of Hypoalbuminemia in Volume Resuscitation and Plasma Expansion with Intravenous Albumin Solution. Int J Mol Sci. 2022;23. [PubMed] [DOI] |
| 52. | Dubois MJ, Orellana-Jimenez C, Melot C, De Backer D, Berre J, Leeman M, Brimioulle S, Appoloni O, Creteur J, Vincent JL. Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study. Crit Care Med. 2006;34:2536-2540. [PubMed] [DOI] |
| 53. | Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, Fanizza C, Caspani L, Faenza S, Grasselli G, Iapichino G, Antonelli M, Parrini V, Fiore G, Latini R, Gattinoni L; ALBIOS Study Investigators. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370:1412-1421. [PubMed] [DOI] |
| 54. | Bannard-Smith J, Alexander P, Glassford N, Chan MJ, Lee M, Wong BT, Crawford G, Bailey M, Bellomo R. Haemodynamic and biochemical responses to fluid bolus therapy with human albumin solution, 4% versus 20%, in critically ill adults. Crit Care Resusc. 2015;17:122-128. [PubMed] |
| 55. | Mårtensson J, Bihari S, Bannard-Smith J, Glassford NJ, Lloyd-Donald P, Cioccari L, Luethi N, Tanaka A, Crisman M, Rey de Castro N, Ottochian M, Huang A, Cronhjort M, Bersten AD, Prakash S, Bailey M, Eastwood GM, Bellomo R. Small volume resuscitation with 20% albumin in intensive care: physiological effects : The SWIPE randomised clinical trial. Intensive Care Med. 2018;44:1797-1806. [PubMed] [DOI] |
| 56. | Alberti LR, Petroianu A, Zac RI, Andrade JC. Relationship between surgical trauma and albumin concentration in the postoperative period of digestive system operations. Minerva Chir. 2008;63:357-362. [PubMed] |
| 57. | Mayerhöfer T, Shaw AD, Wiedermann CJ, Joannidis M. Fluids in the ICU: which is the right one? Nephrol Dial Transplant. 2023;38:1603-1612. [PubMed] [DOI] |
| 58. | Hahn RG, Zdolsek M, Hasselgren E, Zdolsek J, Björne H. Fluid volume kinetics of 20% albumin. Br J Clin Pharmacol. 2019;85:1303-1311. [PubMed] [DOI] |
| 59. | Hasselgren E, Zdolsek M, Zdolsek JH, Björne H, Krizhanovskii C, Ntika S, Hahn RG. Long Intravascular Persistence of 20% Albumin in Postoperative Patients. Anesth Analg. 2019;129:1232-1239. [PubMed] [DOI] |
| 60. | SAFE Study Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group; Australian Red Cross Blood Service; George Institute for International Health; Myburgh J, Cooper DJ, Finfer S, Bellomo R, Norton R, Bishop N, Kai Lo S, Vallance S. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357:874-884. [PubMed] [DOI] |
| 61. | Wiedermann CJ. Use of Hyperoncotic Human Albumin Solution in Severe Traumatic Brain Injury Revisited-A Narrative Review and Meta-Analysis. J Clin Med. 2022; 11. [PubMed] [DOI] |
| 62. | Milford EM, Reade MC. Resuscitation Fluid Choices to Preserve the Endothelial Glycocalyx. Crit Care. 2019;23:77. [PubMed] [DOI] |
| 63. | Lamke LO, Liljedahl SO. Plasma volume expansion after infusion of 5%, 20% and 25% albumin solutions in patients. Resuscitation. 1976;5:85-92. [PubMed] [DOI] |
| 64. | Statkevicius S, Bonnevier J, Fisher J, Bark BP, Larsson E, Öberg CM, Kannisto P, Tingstedt B, Bentzer P. Albumin infusion rate and plasma volume expansion: a randomized clinical trial in postoperative patients after major surgery. Crit Care. 2019;23:191. [PubMed] [DOI] |
| 65. | Jardot F, Hahn RG, Engel D, Beilstein CM, Wuethrich PY. Blood volume and hemodynamics during treatment of major hemorrhage with Ringer solution, 5% albumin, and 20% albumin: a single-center randomized controlled trial. Crit Care. 2024;28:39. [PubMed] [DOI] |
| 66. | Gabarre P, Desnos C, Morin A, Missri L, Urbina T, Bonny V, Turpin M, Baudel JL, Berard L, Montil M, Guidet B, Voiriot G, Joffre J, Maury E, Ait-Oufella H. Albumin versus saline infusion for sepsis-related peripheral tissue hypoperfusion: a proof-of-concept prospective study. Crit Care. 2024;28:43. [PubMed] [DOI] |
| 67. | Yu YT, Liu J, Hu B, Wang RL, Yang XH, Shang XL, Wang G, Wang CS, Li BL, Gong Y, Zhang S, Li X, Wang L, Shao M, Meng M, Zhu F, Shang Y, Xu QH, Wu ZX, Chen DC. Expert consensus on the use of human serum albumin in critically ill patients. Chin Med J (Engl). 2021;134:1639-1654. [PubMed] [DOI] |
| 68. | Callum J, Skubas NJ, Bathla A, Keshavarz H, Clark EG, Rochwerg B, Fergusson D, Arbous S, Bauer SR, China L, Fung M, Jug R, Neill M, Paine C, Pavenski K, Shah PS, Robinson S, Shan H, Szczepiorkowski ZM, Thevenot T, Wu B, Stanworth S, Shehata N; International Collaboration for Transfusion Medicine Guidelines Intravenous Albumin Guideline Group. Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. Chest. 2024. [PubMed] [DOI] |
| 69. | Lee EH, Kim WJ, Kim JY, Chin JH, Choi DK, Sim JY, Choo SJ, Chung CH, Lee JW, Choi IC. Effect of Exogenous Albumin on the Incidence of Postoperative Acute Kidney Injury in Patients Undergoing Off-pump Coronary Artery Bypass Surgery with a Preoperative Albumin Level of Less Than 4.0 g/dl. Anesthesiology. 2016;124:1001-1011. [PubMed] [DOI] |
| 70. | Wu N, Liu T, Tian M, Liu C, Ma S, Cao H, Bian H, Wang L, Feng Y, Qi J. Albumin, an interesting and functionally diverse protein, varies from 'native' to 'effective' (Review). Mol Med Rep. 2024;29. [PubMed] [DOI] |