What is the evidence for using albumin infusion in critical care?

From the Guidelines

Albumin infusion in critical care should not be used as a first-line fluid therapy, except in specific patient populations such as those with cirrhosis and ascites undergoing large-volume paracentesis, where it may be beneficial in preventing paracentesis-induced circulatory dysfunction 1.

Patient Populations

• Critically ill adult patients with thermal injuries or ARDS: intravenous albumin is not suggested for volume replacement or to increase serum albumin level 1
• Critically ill adult patients: intravenous albumin in conjunction with diuretics is not suggested for removal of extravascular fluid 1
• Preterm neonates: intravenous albumin is not suggested to improve respiratory function or for volume replacement 1
• Patients undergoing kidney replacement therapy: intravenous albumin is not suggested for the prevention or treatment of intradialytic hypotension or for improving ultrafiltration 1
• Pediatric patients undergoing cardiovascular surgery: intravenous albumin is not suggested for priming the cardiovascular bypass circuit or for volume replacement 1

Evidence

• A systematic review from 2019 found no mortality benefit when crystalloid was compared with albumin in critical care patients 1
• The Saline Versus Albumin Fluid Evaluation trial demonstrated that albumin was equivalent to normal saline for fluid resuscitation in general ICU patients, but may reduce mortality in sepsis and traumatic brain injury subgroups 1
• A 2020 systematic review and sequential network analysis of RCTs in the setting of sepsis found albumin not to be superior to crystalloids for mortality or acute kidney injury 1

Recommendations

• For hypovolemic patients, crystalloids remain the initial fluid of choice
• Albumin may be beneficial in certain scenarios, such as patients with sepsis requiring substantial fluid resuscitation, or those with spontaneous bacterial peritonitis
• The benefits of albumin must be weighed against costs in resource-limited settings, as it is significantly more expensive than crystalloids 1

From the FDA Drug Label

Emergency Treatment of Hypovolemic Shock Plasbumin-25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. Although Plasbumin-5 is to be preferred for the usual volume deficits, Plasbumin-25 with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed. Burn Therapy ... Beyond 24 hours Plasbumin-25 can be used to maintain plasma colloid osmotic pressure. Hypoproteinemia With or Without Edema During major surgery, patients can lose over half of their circulating albumin with the attendant complications of oncotic deficit.(2,4,5) A similar situation can occur in sepsis or intensive care patients. Treatment with Plasbumin-25 may be of value in such cases. Adult Respiratory Distress Syndrome (ARDS)(2,5) This is characterized by deficient oxygenation caused by pulmonary interstitial edema complicating shock and postsurgical conditions. When clinical signs are those of hypoproteinemia with a fluid volume overload, Plasbumin-25 together with a diuretic may play a role in therapy

The evidence supports the use of albumin infusion in critical care for several indications, including:

• Hypovolemic shock: to expand plasma volume and improve hemodynamics
• Burn therapy: to maintain plasma colloid osmotic pressure beyond 24 hours after injury
• Hypoproteinemia: to treat oncotic deficits and complications associated with major surgery, sepsis, or intensive care
• Adult Respiratory Distress Syndrome (ARDS): to treat hypoproteinemia with fluid volume overload, in combination with a diuretic 2 Key considerations for albumin infusion in critical care include:
• Monitoring for circulatory overload: to guard against the possibility of circulatory overload, especially in patients with dehydration or hemorrhage 2
• Dosage and administration: to adapt the volume and speed of infusion to the individual patient's response, and to avoid excessive hypoproteinemia or circulatory embarrassment 2

From the Research

Indications for Albumin Infusion

• Albumin infusion is indicated for resuscitation in shock states, especially distributive shocks such as septic shock 3
• Liver disease is another main evidence-based indication for albumin administration 3
• Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin 3
• Albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia 3

Benefits of Albumin Infusion

• Albumin has pleiotropic physiological activities including antioxidant effects and positive effects on vessel wall integrity 4
• Its administration facilitates achievement of a negative fluid balance in hypoalbuminemia and in conditions associated with edema 4
• Fluid resuscitation with human albumin is less likely to cause nephrotoxicity than with artificial colloids, and albumin infusion has the potential to preserve renal function in critically ill patients 4
• Albumin 20% infusion can be used for volume expansion in septic patients, with a secondary fluid resorption and volume expansion maximal at 30 min 5

Guidance for Albumin Use

• Large multicenter randomized studies have provided valuable data regarding the safety of albumin solutions, and have begun to clarify which groups of patients are most likely to benefit from their use 6
• A protocol can help guide the decision of when to use albumin infusions in critically ill patients 7
• Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin 3