When is albumin (human albumin) infusion recommended?

When to Infuse Albumin

Albumin infusion is primarily recommended for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis, while it is not recommended for most other clinical scenarios including routine volume replacement or correction of hypoalbuminemia alone. 1

Evidence-Based Indications for Albumin Infusion

Strong Recommendations (Highest Quality Evidence)

1. Complications of Cirrhosis:

   • Large-volume paracentesis (>5 liters) to prevent paracentesis-induced circulatory dysfunction 1
   • Spontaneous bacterial peritonitis to reduce the risk of renal failure and mortality 1
   • Hepatorenal syndrome in conjunction with vasoconstrictors 1

2. Shock States:

   • Hemorrhagic shock as an emergency measure when blood products are not immediately available 2
   • Burns during the first 24 hours (in conjunction with crystalloids) 2
   • Shock associated with acute pancreatitis and peritonitis 2

Weak or Conditional Recommendations

1. Sepsis and Septic Shock:

   • As a second-line fluid after crystalloids in patients requiring large volumes of fluids 1
   • May improve shock reversal and short-term survival in patients with cirrhosis and sepsis-induced hypotension 1

2. Surgical Indications:

   • Significant postoperative albumin loss after major surgeries (radical dissections, colon/rectal surgery, aortic reconstructions) 2

When NOT to Use Albumin

1. Hypoalbuminemia without oncotic deficit 1, 2, 3

   • Hypoalbuminemia alone is not an indication for albumin administration
   • Nutritional supplementation should be addressed through dietary means

2. First-line volume replacement in critically ill patients 1

   • Crystalloids are preferred as initial therapy for hypovolemia

3. Routine maintenance of serum albumin levels 1, 3

   • Targeting specific albumin levels may lead to pulmonary edema and fluid overload 1

Dosing Considerations

• Large-volume paracentesis: 6-8 g of albumin per liter of ascitic fluid removed
• Spontaneous bacterial peritonitis: 1.5 g/kg on day 1, followed by 1 g/kg on day 3
• Hepatorenal syndrome: 1 g/kg on day 1, followed by 20-40 g/day
• Shock states: Dosing based on clinical response and hemodynamic parameters

Potential Adverse Effects

• Fluid overload and pulmonary edema
• Hypotension
• Hemodilution requiring RBC transfusion
• Anaphylaxis (rare)
• Peripheral gangrene from dilution of natural anticoagulants (rare)

Clinical Decision Algorithm

1. Assess the specific clinical scenario:

   • Is the patient cirrhotic with large-volume paracentesis, SBP, or hepatorenal syndrome?
   • Is there hemorrhagic shock without immediate blood product availability?
   • Is there severe burn injury within the first 24 hours?

2. If YES to any of the above: Administer albumin at appropriate dosing

3. If NO: Consider whether the patient has:

   • Septic shock requiring large volumes of crystalloids
   • Major surgery with significant albumin loss
   • Severe pancreatitis or peritonitis

4. If NO to all scenarios: Albumin is likely not indicated; use crystalloids for volume replacement

Important Caveats

• Albumin is expensive and should be used judiciously when indicated
• Balanced crystalloids are preferred for initial fluid resuscitation in most scenarios
• The benefit of albumin in critically ill patients with cirrhosis and/or acute-on-chronic liver failure is not well defined beyond specific indications 1
• Recent evidence suggests albumin may be safe and effective even in patients without AKI and SBP 4, but this requires further validation before changing practice recommendations

Remember that albumin administration should be guided by specific clinical indications rather than arbitrary serum albumin levels or general hypoalbuminemia.