Trials were graded for adequacy of concealment of allocation. The authors report that the overall pooled risk is significantly increased with all trials or with only the high quality trials. Interpretation of this overall pooled risk hinges on whether you believe hypotension and hypovolemia are clinically similar and thus can be pooled. Although this paper appears to provide compelling evidence for increased risk being associated with albumin usage, due to the combination of clinically herterogeneous indications these conclusions are not compelling. Although it would be nice to see length of stay and costs, these are very hard to include in a meta-analysis.
Mortality is probably the most important outcome in each of the clinical scenarios reviewed.
Unsure at this point in time. This is a very interesting article that provides a comprehensive list of albumin based trials in critically ill patients. The weight you put on the importance of the findings depends on whether you believe that the managment of the hypovolemic and hypoalbuminemic patients are similar enough to pool. We should consider the possibility that albumin usage may be associated with increased harm, but due to methodologic concerns, this conclusion is open for debate.