What is the role of human albumin in Intensive Care Unit (ICU) settings?

From the Guidelines

Human albumin should not be routinely used for fluid resuscitation in most ICU patients, and its use should be reserved for specific clinical scenarios where its benefits have been established, such as cirrhosis and spontaneous bacterial peritonitis, severe sepsis with persistent hypotension, or large volume paracentesis. The rationale for limited use stems from albumin's high cost compared to crystalloids without clear mortality benefit in most ICU patients, as highlighted in recent guidelines 1. Albumin works by increasing oncotic pressure, drawing fluid into the intravascular space, but this theoretical advantage doesn't translate to improved outcomes in general critical care.

Some studies have suggested potential benefits of albumin in specific contexts, such as improved circulatory function and lower volume of vascular load 1. However, these benefits are not sufficient to justify routine use of albumin in ICU patients. The 2021 Surviving Sepsis Campaign suggested using albumin in addition to crystalloids as fluid therapy in sepsis and septic shock patients requiring large volumes of saline, but the level of evidence is not sufficient to justify a strong recommendation 1.

Key considerations for the use of albumin include:

• High cost compared to crystalloids
• Lack of clear mortality benefit in most ICU patients
• Potential benefits in specific clinical scenarios, such as cirrhosis and spontaneous bacterial peritonitis, severe sepsis with persistent hypotension, or large volume paracentesis
• Improved circulatory function and lower volume of vascular load in some studies

Crystalloids like normal saline or balanced solutions (Lactated Ringer's, PlasmaLyte) should be first-line for most fluid resuscitation needs, with albumin reserved for the specific indications mentioned. The most recent and highest quality study, published in 2022, supports this approach 1.

From the Research

Human Albumin in ICU

• Human albumin is used in various medical and surgical problems, including shock, burns, and hypoproteinaemia 2, 3, 4.
• The use of human albumin in critically ill patients has been a topic of debate, with some studies suggesting that it may increase the risk of death 3, 4.
• A systematic review and meta-analysis of randomized controlled trials found that human albumin solutions as part of fluid volume expansion and resuscitation for critically unwell adults with sepsis of any severity were not robustly effective at reducing all-cause mortality 5.
• Another study found that albumin administration is most indicated in the management of cirrhosis complications, fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments 2.
• The use of human albumin in ICU patients with sepsis has been studied, and the results suggest that it may not be beneficial in reducing mortality 6, 5.
• The quality of evidence for the use of human albumin in ICU patients varies, with some studies having a high quality of evidence and others having a low quality of evidence 2, 5.

Indications for Human Albumin

• Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis 2.
• Resuscitation in shock states, especially distributive shocks such as septic shock 2, 6.
• Treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments 2.

Safety and Efficacy

• Human albumin solutions are more expensive than other colloids and crystalloids 3, 4.
• The use of human albumin in critically ill patients may increase the risk of death 3, 4.
• However, other studies suggest that human albumin is safe in critically ill patients with sepsis, and a signal towards harm was not detected 5.