What is the role of albumin in the management of septic shock?

From the Guidelines

Albumin should not be used as first-line therapy in the management of septic shock, and crystalloid solutions should be the initial choice for fluid resuscitation. The use of albumin in septic shock is a topic of ongoing debate, with some studies suggesting potential benefits and others showing no clear advantage over crystalloids. According to the most recent and highest quality study 1, five randomised controlled trials have assessed the impact of albumin on mortality in septic patients, with no benefit shown in high-quality studies. The SAFE study 1 is the largest randomised trial on the subject, and while post-hoc analysis suggested a favourable effect of albumin on mortality, this has not been consistently replicated in other studies. Some key points to consider when deciding on the use of albumin in septic shock include:

• Theoretical benefits of albumin, such as its oncotic properties, potential binding of inflammatory mediators and toxins, and antioxidant effects
• Lack of consistent evidence for improved mortality with albumin in septic shock
• Higher cost of albumin compared to crystalloids
• Potential for allergic reactions to albumin in some patients
• Importance of early, adequate fluid resuscitation with crystalloids, appropriate antibiotic therapy, source control, and vasopressor support as the cornerstones of septic shock management. In general, crystalloid solutions, such as normal saline or lactated Ringer's, should be used initially for fluid resuscitation in septic shock 1. Albumin may be considered as a second-line option in patients who require substantial amounts of crystalloids or in those with hypoalbuminemia (serum albumin <3 g/dL) 1.

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. (2) 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. (2)

The role of albumin in the management of septic shock is to treat hypoproteinemia and oncotic deficits that may occur in these patients. Albumin administration may be of value in supporting blood volume and colloid osmotic pressure in septic patients 2.

• Key points:
  • Albumin may be used to treat hypoproteinemia and oncotic deficits in septic patients.
  • Administration of albumin may help support blood volume and colloid osmotic pressure.
  • The use of albumin in septic shock is based on its ability to expand plasma volume and provide oncotic support 2.
  • However, the decision to use albumin should be individualized and based on the patient's specific clinical situation 2.

From the Research

Role of Albumin in Septic Shock

• Albumin can be considered in some clinical settings for volume expansion during septic shock, although crystalloids are still the first-choice fluid for volume resuscitation 3.
• The use of albumin resuscitation in septic shock is only recommended in patients who have received large volumes of crystalloid resuscitation, regardless of serum albumin concentration 4.
• Studies have shown that albumin replacement may not increase the number of vasopressor-free days in patients with septic shock and hypoalbuminemia, but it may reduce the need for invasive mechanical ventilation 4.

Benefits and Limitations of Albumin

• Albumin has pleiotropic physiological activities, including antioxidant effects and positive effects on vessel wall integrity, which may be beneficial in septic shock 5.
• Albumin administration can facilitate achievement of a negative fluid balance in hypoalbuminemia and in conditions associated with edema 5.
• However, meta-analyses have found no significant effect of albumin-containing fluids on mortality in patients with sepsis of any severity, and crystalloids are recommended as the first choice for fluid resuscitation due to cost-effectiveness 6.

Clinical Guidelines and Recommendations

• Current guidelines recommend crystalloids as the initial fluid solution of choice in the resuscitation of patients with severe sepsis and septic shock, with balanced crystalloids considered as an alternative to normal saline 7.
• Semi-synthetic colloids are not recommended due to decreased survival, and the role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain 7.
• Further studies are needed to assess the effect of albumin replacement on patient outcomes in septic shock, particularly in patients with hypoalbuminemia 4, 5.