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. 2025 Aug 1;13(1):43.
doi: 10.1186/s40560-025-00813-y.

Re-evaluating albumin use in traumatic brain injury

Jean-Louis Vincent  1 , Ricard Ferrer  2   3   4 , Fabio S Taccone  5 , Christian J Wiedermann  6 , Peter Reinstrup  7
Affiliations

Re-evaluating albumin use in traumatic brain injury

Jean-Louis Vincent et al. J Intensive Care. .

Abstract

Traumatic brain injury (TBI) affects approximately 69 million people annually, with the majority of cases being mild-to-moderate in severity. However, in severe TBI, early management is critical and includes fluid resuscitation to control intracranial pressure (ICP) and optimize cerebral perfusion pressure. The SAFE-TBI study linked hypotonic 4% albumin to higher mortality versus saline (33.2% vs. 20.4%; RR 1.63; P = 0.003), likely due to elevated ICP, prompting guidelines favoring saline. However, these recommendations are based on low-quality evidence and overlook hyperoncotic albumin. Preclinical data confirm that hypotonicity-not albumin-drives ICP elevation. Emerging data suggest that hyperoncotic albumin (20-25%) may reduce ICP and improve outcomes. This letter highlights evidence gaps and advocates re-evaluating albumin use in TBI, especially hyperoncotic formulations.

Keywords: Albumin; Intracranial pressure; Outcomes; Traumatic brain injury.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: JLV, RF and FST have received consultancy fees from Grifols. CJW received fees for speaking and/or consulting from CSL Behring and Grifols. PR has no competing interests to declare.

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