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Furosemide and albumin improve oxygenation in a small group of patients with Acute Lung Injury.

Citation/s: Martin GS, Moss M, Wheeler A, Mealer M, Morris J, Bernard G: A randomised, controlled trial of furosemide with or without albumin in hypoproteinaemic patients with acute lung injury. Crit Care Med. 2005; 33:1681-7

Three-part Clinical Question:

Patients: Hypoproteinaemic patients with acute lung injury.

Intervention: Treatment of furosemide with or without albumin.

Outcome:  Improved oxygenation.

Search Terms: acute respiratory distress syndrome; acute lung injury, albumin; blood proteins; hydrostatic pressure; hypoproteinaemia; lung diseases; osmotic pressure

The Study: Double-blinded concealed randomised multi-centred controlled trial with intention-to-treat. In 11 medical, surgical and trauma ICUs in North America.

The Study Patients: Patients were eligible that had each of the following criteria: American-European Consensus Conference definition for ALI, serum total protein level ≤6.0g/dl, ongoing nutritional support and mechanical ventilation for >24hrs. Patients were excluded for haemodynamic instability, renal or liver disease, allergy, pregnancy, age <18 and biochemical abnormality of either sodium or potassium. There was no difference between control and study group.

 
Control group (N = 20; 20 analysed): 20 mg furosemide bolus then 4mg/hr for 4 hours, and titrated every 4 hours to gain net negative fluid balance over a total of 72hrs. Trial intervention suspended for systemic hypotension, with appropriate fluid or vasopressor therapy as required. Standard ICU care with no extra diuretic or colloid therapy permitted. Placebo of 100ml bolus of saline every 8hrs for 72hrs.

Experimental group (N = 20; 20 analysed): As above with 25g of 25% albumin (100ml) every 8hrs for 72hrs.

The Evidence:

EBM Questions:

1)      Do the methods allow accurate testing of the hypothesis? Yes

2)      Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes

3)      Are conclusions valid in light of the results? Yes

4)      Did results get omitted, and why? No

5)      Did they suggest areas of further research? Yes. Their suggestion is that a large-scale randomised trial is warranted to determine clinical benefit in mechanical ventilation.

6)      Did they make any recommendations based on the results and were they appropriate? No

7)      Is the study relevant to my clinical practice? To a limited extent, Yes. The small number of patients in this study (n=40) with the large number of excluded patients (n=309) make this a minority subgroup of hypoproteinaemic patients with acute lung injury but without shock. Additionally, there was no proven improvement in patient survival.

8)      What level of evidence does this study represent? Level 1^- (RCT with a high risk of bias due to small sample size.)

9)      What grade of recommendation can I make on this result alone? None

10)  What grade of recommendation can I make when this study is considered along with other available evidence? None.

11)  Should I change my practice because of these results? No

12)  Should I audit my current practice because of these results? Yes, if you use furosamide and albumin in ALI patients you should review your practice

Appraised by: David MacNair and Dr BH Cuthbertson, Intensive Care Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN ; 13 September 2005

Email: davidmacnair@doctors.net.uk

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. 2006 & JICS 2006 Vol7(2). MacNair D, Cuthbertson BH: Martin GS, Moss M, Wheeler A, Mealer M, Morris J, Bernard G: A randomised, controlled trial of furosemide with or without albumin in hypoproteinaemic patients with acute lung injury. Crit Care Med. 2005; 33:1681-7

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