This controversy-starting retrospective study reported a 30% reduction in 3 year recurrence-free survival after undergoing mastectomy for primary breast cancer in patients who received a traditional general anaesthetic with morphine analgesia, compared with those receiving a regional (paravertebral) technique.
Although plausible biological mechanisms have been suggested and even demonstrated in vitro, the huge treatment effect is yet to be replicated in better quality retrospective or prospective trials.
Evidence to date does not (yet) support this trial’s findings.
"An extraordinary claim requires extraordinary proof." – Marcello Truzzi
In traumatic brain injury resuscitation with albumin is associated with a higher mortality than resuscitation with saline.
ICU resuscitation with either normal saline or 4% albumin results in similar outcomes, in the absence of traumatic brain injury.
High troponin levels pre-operatively are associated with cardiac events and mortality after non-cardiac surgery.
Elective surgery should be delayed at least 9 months after stroke or cerebrovascular event, although there is a persisting increased risk of perioperative stroke in these patients.
Why this is interesting...
In many ways, human albumin might be the perfect colloid fluid – and concentrated 20% albumin could be the ideal resuscitation fluid in the critical care setting, where fluid overload is otherwise a common consequence. Because of its high relative concentration, the intravascular expansion effect of 20% albumin is roughly double its infused volume, unlike 4% or 5% albumin.
In the SWIPE trial Mårtensson et al showed that even in the leaky-capillary state of critical illness, resuscitation with 20% albumin decreased fluid needs, lessened positive fluid-balance states, and was not associated with harm when compared to 4-5% albumin.
What did they do?
This was a well designed multicentre trial across three adult Australian & UK ICUs. 321 patients were randomized to either 20% or 4-5% albumin resuscitation during their first 48h in ICU.
Probably the most important takeaway is simply that resuscitation with 20% albumin is practical and results in no patient harm compared with 4-5%. The 576mL median lower difference in fluid balance is unlikely alone to be dramatically consequential.
Nonetheless an important first step before larger studies can look at morbidity and mortality outcomes.
Cautiously note though that for logistic reasons the trial was open label, so treating clinicians were well aware of which fluid they were using. Additionally, they were given free reign to choose additional resuscitation fluids (crystalloid or synthetic colloid) as the clinical situation required.
The intravascular expansion effect of 20% albumin is roughly double its infused volume, although 15% greater again in the healthy versus those with sepsis.
This update to their 2011 meta-analysis supports their conclusion that aspirin modestly reduces myocardial infarction when used for primary prevention, but at the expense of increased risk of intracranial and major bleeding.
Although daily low-dose aspirin reduces vascular events in those with diabetes but no cardiovascular history, it does this at the expense of major hemorrhage risk.