From the Guidelines
The use of albumin in hypoalbuminemia with sepsis is not routinely recommended as a first-line treatment. While albumin can theoretically help restore oncotic pressure and improve fluid balance, its clinical benefits in sepsis are limited and controversial, as shown in a systematic review from 2019 1. Instead, the primary focus should be on treating the underlying sepsis with appropriate antibiotics, source control, and supportive care including judicious fluid management with crystalloids.
Key Points to Consider
- The Surviving Sepsis Campaign guidelines recommend crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock, with albumin considered only when patients require substantial amounts of crystalloids 1.
- A systematic review from 2018 conducted by the Cochrane collaboration found no difference in mortality in patients in the ICU when patients managed with crystalloids were compared with those managed with albumin 1.
- The largest randomized trial, the Saline Versus Albumin Fluid Evaluation trial, found no differences in outcomes, including 28-day mortality, when comparing 4% albumin with 0.9% normal saline 1.
Specific Considerations for Albumin Use
In specific cases where severe hypoalbuminemia (typically <2 g/dL) is present along with refractory shock or significant edema, albumin administration may be considered. The typical dose is 25% albumin solution, 50-100 mL over 30-60 minutes, which can be repeated based on clinical response and albumin levels. However, this should be done cautiously and only after careful evaluation of the patient's overall fluid status and cardiac function.
Rationale for Limited Albumin Use
The rationale for limited albumin use is that while it can temporarily increase oncotic pressure, it doesn't address the underlying cause of sepsis-induced capillary leak. Moreover, albumin is expensive, and studies have not consistently shown improvements in mortality or organ function compared to crystalloid solutions in most sepsis patients. The focus should remain on early, appropriate antibiotic therapy, hemodynamic support, and addressing the source of infection, which are more likely to improve outcomes in sepsis.
From the FDA Drug Label
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. Sequestration of Protein Rich Fluids(7) This occurs in such conditions as acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis. The magnitude of loss into the third space may require treatment of reduced volume or oncotic activity with an infusion of albumin
The benefits of administering albumin in patients with hypoalbuminemia and sepsis include:
- Supporting oncotic pressure to prevent or treat complications related to oncotic deficit
- Treating reduced volume or oncotic activity caused by sequestration of protein-rich fluids in conditions such as acute peritonitis, pancreatitis, and extensive cellulitis 2
From the Research
Benefits of Administering Albumin in Patients with Hypoalbuminemia and Sepsis
The administration of albumin in patients with hypoalbuminemia and sepsis has several benefits, including:
- Fluid resuscitation and treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments 3
- Reduction of intradialytic hypotension and improvement of fluid removal in patients receiving renal replacement therapy 4
- Antioxidant properties, which may be beneficial in critically ill patients to limit oxidative damage 5
- Potential beneficial effects on organ function, although the exact mechanisms remain undefined 5
- Facilitation of achievement of a negative fluid balance in hypoalbuminemia and in conditions associated with edema 6
- Preservation of renal function in critically ill patients, as fluid resuscitation with human albumin is less likely to cause nephrotoxicity than with artificial colloids 6
Indications for Albumin Administration
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 3. Additionally, albumin may be beneficial in patients with sepsis, as it has pleiotropic physiological activities including antioxidant effects and positive effects on vessel wall integrity 6.
Volume Resuscitation and Plasma Expansion
The volume effects of intravenous human albumin solution exceed those of crystalloid solutions, and hypoalbuminemia acts as an effect moderator in volume resuscitation and plasma expansion with albumin solution 4. The volume effectiveness of intravenous human albumin solution in resuscitation appears to be greater when the serum albumin levels are low 4.
Phases of Fluid Management
Human albumin solution has been investigated in different phases of restrictive fluid resuscitation, and its use has been shown to facilitate restrictive fluid therapy and the effectiveness of deresuscitative measures 7. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis, and hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function 7.