CABG --why is IV albumin given?

SBURNSTEVEN · Oct 7, 2014

Post op day 0. H/h was 9.1/27.7 Albumin was given. Please explain why? Wouldn't the Albumin dilute the h/h further? Blood wasn't given, the reasoning was because blood products have a higher incidence of causing lung injury in intubated patients.

Home Health Columnist / Guide · Oct 7, 2014

Infusion of human albumin causes, within a few minutes, the movement of fluids from the interstitial space into the circulation. When IV fluids are maxed , it may be administered to expand the intravascular volume and maintain circulation.

Albumin

Cardiopulmonary Bypass

An adequate blood volume during cardiopulmonary bypass can be maintained with crystalloids as the only pump priming fluid, but only at the price of interstitial edema. A commonly employed program is an AlbuRx® 25, Albumin (Human) 25% solution and crystalloid pump prime adjusted so as to achieve a hematocrit of 20% and a plasma albumin level of 2.5 g/100 mL in the patient, but the level to which either may be lowered safely has not yet been defined.17

Article: The Role of Albumin in Fluid and Electrolyte Balance

Esme12, ASN, BSN, RN · Oct 7, 2014

an "unobtainable" blood loss...there was no EBL at all? Are you a student? New grad?

going on bypass is tough on the body... let alone manhandling the heart...which is unaccustomed to manhandling.

Having your circulating blood volume leave your body and return repetitively is traumatic. The shifting of fluid causes third spacing. The large volume loss causes shock and compensatory mechanisms to kick in...the instability is the body trying to compensate with vasoconstriction (B/P up) with shock because the well (the heart) is empty/dry (volume loss) when a patient is fluid resuscitated in the OR they can receive large quantities of not only blood but IVF (crytalloids) because they need tons of volume fast. The fix is temporary. Nursing Center - I.V. fluids: What nurses need to know

So the patient is extravascular overloaded intravascular depleted. CV Physiology: Tissue Edema and General Principles of Transcapillary Fluid Exchange

Albumin pulls the fluid from the tissues back into circulation

Intravenous Fluid Resuscitation: Shock and Fluid Resuscitation: Merck Manual Professional

SubSippi · Oct 7, 2014

H/h wasn't low enough to warrant blood. You can tell if a person is "dry" by their hemodynamics...CVP and PCWP. If those are low, it's likely the person is dry. Blood pressure isn't as good of an indicator of fluid volume, because their blood vessels could have clamped down to compensate, or it could be due to pressors given in the OR.

SBURNSTEVEN · Oct 12, 2014

H/h wasn't low enough to warrant blood. You can tell if a person is "dry" by their hemodynamics...CVP and PCWP. If those are low, it's likely the person is dry. Blood pressure isn't as good of an indicator of fluid volume, because their blood vessels could have clamped down to compensate, or it could be due to pressors given in the OR.

Let's just focus on CVP.....normal is about 1-8 (depending on source). Since the patient is Post CABG is the normal CVP inadequate because we know the patient lost blood? Should we aim for a CVP around 10 as we tut rate down Levophed? This seems to be how it's done on the ct ICU floor I am orientations on.

Esme12, ASN, BSN, RN · Oct 13, 2014

Let's just focus on CVP.....normal is about 1-8 (depending on source). Since the patient is Post CABG is the normal CVP inadequate because we know the patient lost blood? Should we aim for a CVP around 10 as we cut rate down Levophed? This seems to be how it's done on the ct ICU floor I am orientations on.

Did the patient have a PA catheter?

It depends on the patient and the numbers....as well as the clinical picture of what happened in the OR. SOME I repeat SOME patient require higher filling pressures (CVP)...to maintain the B/P. Depending on the Cardiac output/SVR Cardiac index helps determine the weaning of drips. If the SVR is low the patient is vasodialted with an an empty tank so you need t replace volume before decreasing the drips.

Depending on the patient the CVP might be more elevated that the PCWP due to right ventricular insufficiency/failure causing back up in the right heart....the wedge pressure is more accurate of the volume status...in usual circumstances.

How long have you been a nurse?

Untitled Document

https://lane.stanford.edu/portals/cvicu/HCP_CV_Tab_1/Intracardiac_Pressures.pdf

CV Pharmacology: Pulmonary Arterial Pressure

Esme12, ASN, BSN, RN · Oct 13, 2014

http://ocw.tufts.edu/data/50/636804.pdf

SBURNSTEVEN · Oct 13, 2014

Thanks, I've been working on a med-surg floor for a year and a half and I'm orientating in CT ICU now.

allnurses Guide · Oct 18, 2014

You give albumin as an alternative to blood when you need expansion of your intravascular volume but don't have severe anemia. In CT surgery postop world, severe anemia requiring transfusion is often

RN-LOGIC · Oct 30, 2014

My advice to you is not to focus only on one hemodynamic number. You have to look at the entire picture and then some. For example, a low H and H is not the only factor taken into account when deciding to transfuse blood. Is the balance of 02 delivery and 02 demand adequate for the patient to meet tissue oxygenation? You don't know? Take a look at your svo2. Is it low? Is your patient bleeding or simply hemodiluted. Check a lactate or anion gap just to check its adequacy by correlation. *Side note* There are other factors that can influence your oxygen delivery such as oxygenation and cardiac output. Did I say cardiac output can affect your Oxygen delivery? Well, the less stroke volume, the less oxygenated blood circulating. So, maybe in this case giving plasmanate (albumin) can increase your 02 delivery without the unnecessary risks of giving blood in this instance. In the management of hypotension for post CABG patients, increasing the patient's heart rate by use of the epicardial pacemaker is the fastest way to see results in the BLOOD PRESSURE. Remember, the pacemaker is your best friend, use it. Now, we look at the cvp/cardiac index**** you must know your patient's EF/LV FUNCTION/Tricuspid regurgation/RVH/PULM. HTN. Give fluid? maybe not. Fluid challenge sounds better----> assess for fluid responsiveness. Look at your Mean arterial pressure and afterload considering AI/MITRAL STENOSIS/LVH----> hIGH AFTERLOAD WHICH TRANSLATES INTO HIGH BLOOD PRESSURE AND INCREASE HEART WORKLOAD AND INCREASED 02 DEMAND, NOT BUENO(GOOD). I suspect that your patient was vasoconstricted due to IDK maybe hypothermia or a compensatory mechanism or etc. The have started a whiff of nipride, yikes your friend dilate just showed up you better invite fill to compensate. Bang...............

PamsaRN · Oct 31, 2014

Great reply post....I always remember Albumin at a heart shaped molecule(a protein). It's job is to help control osmotic BP....or the fluids that can slip in and out of the blood stream...have you ever had a older pt that has "weeping" skin? Their skin looks thin as tissue with lots of soft wrinkles and it actually weeps a clear fluid. This is from low albumin. They are "leaking". Albumin also acts as a "taxi" carrying other proteins in blood plasma that are important to a post surgical pt like ipid soluble hormones, bile salts, unconjugated bilirubin, free fatty acids (apoprotein), calcium, ions (transferrin), and some drugs like warfarin, phenobutazone, clofibrate & phenytoin. Hope this helps you to understand Albumin. Remember this always.....never be afraid to ask a question or clear any confusion you may have.....learning never stops no matter how experienced or old you are! :)