What is the recommended dosing and administration of terlipressin and albumin for hypotension in a critical care setting?

Terlipressin and Albumin Dosing for Hypotension in Critical Care

Terlipressin should be administered at an initial dose of 1 mg IV every 6 hours with albumin 1 g/kg on day 1 followed by 20-40 g/day in patients with hypotension due to hepatorenal syndrome in the critical care setting. 1, 2

Terlipressin Administration Protocol

Initial Dosing

• Start with 1 mg IV bolus every 6 hours (4 mg/day total) 1, 3
• Administer as an IV bolus over 2 minutes through a peripheral line 1
• No ICU monitoring required unless patient has ACLF grade 3 or respiratory concerns 1

Dose Titration

• If serum creatinine decreases <30% by day 4, increase dose to 2 mg every 6 hours 1, 3
• Maximum treatment duration: 14 days 1
• Treatment can be discontinued 24 hours after creatinine decreases to <1.5 mg/dL 1

Alternative Administration Method

• Continuous IV infusion is an equally effective alternative 1, 4
• Start at 2 mg/day and increase every 24-48 hours up to 12 mg/day 1, 4
• Continuous infusion shows lower rates of adverse events and requires lower total daily doses (2.23 mg/day vs 3.51 mg/day with bolus dosing) 4

Albumin Administration Protocol

Initial Dosing

• Day 1: 1 g/kg body weight (maximum 100 g) 1, 3
• Subsequent days: 20-40 g/day 1

Duration and Monitoring

• Continue albumin throughout terlipressin treatment 1
• Reassess need for continued albumin after 1-2 days based on volume status 2
• Consider using point-of-care ultrasonography to guide albumin administration 1
• Monitor closely for pulmonary edema, especially with pre-existing cardiac dysfunction 2

Contraindications and Precautions

Absolute Contraindications

• Hypoxemia (SpO₂ <90%) 1, 2
• Ongoing coronary, peripheral, or mesenteric ischemia 1
• Serum creatinine >5 mg/dL 1, 2

Monitoring Requirements

• Baseline oxygen saturation before starting treatment 2
• Regular monitoring of vital signs every 2-4 hours 1
• Monitor for ischemic complications (abdominal pain, digital ischemia) 1
• Watch for signs of pulmonary edema, particularly with higher albumin doses 1

Efficacy Considerations

Predictors of Better Response

• Serum bilirubin ≤10 mg/dL 2
• Lower ACLF grades 2
• Normal cardiac function 2
• Early initiation of therapy 2

Evidence of Efficacy

• Combined terlipressin-albumin therapy shows significantly higher response rates (76.5%) compared to albumin alone 5
• Terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin (70.4% vs 28.6% recovery rate) 6
• Continuous infusion achieves similar efficacy with fewer side effects compared to bolus dosing 4

Alternative Vasopressors

If terlipressin is unavailable:

• Norepinephrine: Start at 0.5 mg/hour, increase every 4 hours by 0.5 mg/hour up to 3 mg/hour 1
  • Target: increase mean arterial pressure by ≥10 mmHg or urine output >200 mL/4 hours 1
  • Requires ICU admission 2
• Midodrine and octreotide combination (less effective than terlipressin) 1, 6
  • Midodrine: 7.5-12.5 mg orally three times daily 1
  • Octreotide: 100-200 μg subcutaneously three times daily 1

By following this evidence-based protocol for terlipressin and albumin administration, clinicians can optimize outcomes for patients with hypotension in the critical care setting, particularly those with hepatorenal syndrome.