From the Guidelines
Albumin should be administered after paracentesis of more than 5 liters at a dose of 8 grams of albumin per liter of ascites removed. This recommendation is based on the highest quality evidence available, which suggests that albumin infusion after large-volume paracentesis can prevent post-paracentesis circulatory dysfunction, a condition that can lead to serious complications such as renal impairment, hepatic encephalopathy, and death 1. The use of albumin in this context is crucial to maintain intravascular volume and prevent fluid shifts from the intravascular space to the peritoneal cavity, which can cause relative hypovolemia.
Key Considerations
- The recommended dose of albumin is 8 grams per liter of ascites removed, which is supported by high-quality evidence 1.
- Albumin administration is particularly important for paracentesis of more than 5 liters, as this is associated with a higher risk of post-paracentesis circulatory dysfunction.
- For paracentesis of less than 5 liters, albumin may not be necessary unless the patient has specific risk factors such as acute-on-chronic liver failure (ACLF) or a high risk of post-paracentesis acute kidney injury 1.
- The administration of albumin should occur immediately after the procedure or within a reasonable timeframe, and patients should be monitored for signs of circulatory dysfunction after the procedure, regardless of whether albumin was administered.
Rationale
The rationale for albumin administration after paracentesis is to prevent complications associated with large-volume fluid removal, including hypotension, renal impairment, and electrolyte disturbances. By maintaining intravascular volume, albumin infusion can help to prevent these complications and improve patient outcomes. This is supported by evidence from studies such as those published in Gut 1 and Hepatology 1, which highlight the importance of albumin administration in preventing post-paracentesis circulatory dysfunction.
From the FDA Drug Label
Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume.
- Timing of administration: The FDA drug label does not specify the exact timing of albumin administration after paracentesis.
- Indication for use: Albumin infusion may be required to support blood volume in patients with cirrhosis who undergo paracentesis and are at risk of hypovolemic shock 2.
- Key consideration: The decision to administer albumin should be based on the patient's individual needs and hemodynamic response, with careful monitoring to avoid circulatory overload.
From the Research
Albumin Administration After Paracentesis
- The use of albumin after large-volume paracentesis (LVP) is a common practice to reduce the incidence of postparacentesis circulatory dysfunction (PICD) among patients with cirrhosis and tense ascites 3, 4, 5, 6.
- However, the optimal timing and dosage of albumin administration are not well established.
Comparison with Vasoconstrictors
- Studies have compared the effectiveness of albumin with vasoconstrictors such as midodrine in preventing PICD 3, 4, 5, 6.
- The results suggest that midodrine may not be as effective as albumin in preventing PICD, especially in patients with hepatocellular carcinoma (HCC) 4, 5.
- However, one study found that midodrine was as effective as albumin in reducing morbidity and mortality among patients with refractory ascites undergoing LVP, at a significantly lower cost 3.
Standardization of Albumin Use
- A study found that standardizing the use of albumin in LVP using an order set resulted in a significant reduction in the amount of albumin given, with no difference in adverse effects 7.
- The order set standardized albumin doses to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L) 7.