Intraoperative Use of Albumin in Major non-cardiac surgery: Incidence, Variability, and Association with Outcomes

The impact of albumin use during major surgery is unknown, and a dearth of evidence governing its use in major non-cardiac surgery has long precluded its standardization in clinical guidelines.In this study we investigate institutional variation in albumin use among medical centers in the United States during major non-cardiac surgery and explore the association of intraoperative albumin administration with important post-operative outcomes.The study is an observational retrospective cohort analysis performed among 54 hospitals in the Multicenter Perioperative Outcomes Group (MPOG) and includes adult patients who underwent major non-cardiac surgery under general anesthesia between January 2014 and June 2020. The primary endpoint was the incidence of albumin administration. Secondary endpoints acute kidney injury (AKI), net-positive fluid balance, pulmonary complications, and 30-day mortality. Albumin-exposed and -unexposed cases were compared within a propensity score-matched cohort to evaluate associations of albumin use with outcomes.Among 614,215 major surgery cases, albumin was used in 15.3% (mostly isooncotic albumin) but with significant inter-institutional variability in use patterns. Cases involving intraoperative albumin administration were of a higher American Society of Anesthesiologists (ASA) physical status and received larger infused crystalloid volumes, had higher blood loss, and vasopressor use. Overall, albumin was most often administered at high-volume surgery centers with academic affiliation, and within a propensity score-matched cohort (n=153,218), the use of albumin was associated with AKI (aOR 1.24, 95% CI 1.20-1.28, P0.001), severe AKI (aOR 1.45, 95% CI 1.34-1.56, P0.001), net-positive fluid balance (aOR 1.18, 95% CI 1.16-1.20, P0.001), pulmonary complications (aOR 1.56, 95% CI 1.30-1.86, P0.001), and 30-day all-cause mortality (aOR 1.37, 95% CI 1.26-1.49, P0.001).Intravenous albumin is commonly administered among non-cardiac surgeries with significant inter-institutional variability in use in the United States. Albumin was associated with an increased risk of postoperative complications.