What are the indications for intravenous (IV) albumin?

Indications for IV Albumin

IV albumin should only be used in specific clinical scenarios with evidence-based support, primarily in patients with cirrhosis undergoing large-volume paracentesis (>5L) or with spontaneous bacterial peritonitis, as these are the only two conditions with sufficient evidence to support its routine use. 1, 2

Evidence-Based Indications for IV Albumin

Strong Evidence (Recommended Use)

1. Cirrhosis complications:
   • Large-volume paracentesis (>5L): 6-8g albumin per liter of ascitic fluid removed 1, 2
   • Spontaneous bacterial peritonitis: 1.5g/kg on day 1, followed by 1g/kg on day 3 1, 2

Limited Evidence (Conditional Use)

1. Hepatorenal syndrome: Used in conjunction with vasoconstrictors like terlipressin 1, 2

   • Note: The International Collaboration for Transfusion Medicine Guidelines (ICTMG) states there is insufficient evidence to support routine use in this setting 1

2. Severe sepsis/septic shock: Consider when patients require large volumes of crystalloids 1

   • The 2021 Surviving Sepsis Campaign guidelines suggest albumin as second-line fluid after crystalloids 1

3. Fluid replacement in plasmapheresis: When large volumes of plasma are exchanged 3

Not Recommended (Insufficient Evidence)

1. Critical care settings:

   • Not recommended as first-line volume replacement in critically ill adults 1, 2
   • Not recommended to increase serum albumin levels in hypoalbuminemia alone 1, 2

2. Nutritional support:

   • Not recommended for protein nutrition in chronic cirrhosis, malabsorption, or undernutrition 2

3. Hypoalbuminemia without specific indications 3, 4

4. Routine use in most ICU patients 1, 2

Administration Guidelines

Dosing

• Large-volume paracentesis: 6-8g albumin per liter of ascitic fluid removed 2
• Spontaneous bacterial peritonitis: 1.5g/kg on day 1, followed by 1g/kg on day 3 2
• Hypovolemic shock: Volume and infusion speed should be adapted to individual patient response 5
• Burns: Maintain plasma albumin concentration at 2.5±0.5 g/100mL 5
• Hypoproteinemia: Usual daily dose is 50-75g for adults and 25g for children 5

Administration Method

• Always administer by intravenous infusion 5
• May be administered undiluted or diluted in 0.9% Sodium Chloride or 5% Dextrose in Water 5
• For sodium restriction, administer undiluted or diluted in sodium-free solutions 5
• In hypoproteinemic patients, do not exceed infusion rate of 2mL per minute to avoid circulatory embarrassment and pulmonary edema 5

Important Considerations

Contraindications and Precautions

• Fluid overload
• Risk of hypotension
• Hemodilution requiring RBC transfusion
• Anaphylaxis
• Peripheral gangrene from dilution of natural anticoagulants 2

Cost-Effectiveness

• Albumin is expensive (approximately $130/25g in US dollars) 1, 2
• Requires large volumes of plasma for manufacturing 2
• Crystalloids are equally effective and significantly less expensive for volume replacement in many cases 2

Emerging Research

Five ongoing RCTs will provide additional clarity on albumin use in:

• Intensive care patients with infection
• High-risk adult cardiac surgery
• Acute kidney injury requiring kidney replacement therapy
• Outpatients with decompensated cirrhosis 1

The evidence clearly demonstrates that albumin has specific, limited indications where it provides clinical benefit, but should not be used routinely for volume replacement or correction of hypoalbuminemia alone. Implementation of evidence-based guidelines can effectively reduce inappropriate albumin use.