Why is albumin (human albumin) administered after paracentesis (percutaneous abdominal paracentesis)?

Albumin Administration After Paracentesis: Prevention of Circulatory Dysfunction

Albumin should be administered after large-volume paracentesis (>5L) at a dose of 8g per liter of ascites removed to prevent paracentesis-induced circulatory dysfunction (PICD), which can lead to increased morbidity and mortality. 1

Rationale for Albumin Administration

Albumin infusion after paracentesis serves several critical purposes:

1. Prevention of PICD: Large-volume paracentesis can cause significant hemodynamic changes that lead to PICD in up to 70% of untreated patients 1

2. Reduced Complications: Albumin administration significantly reduces:

   • Hyponatremia (42% reduction)
   • Renal impairment
   • Mortality (36% reduction) 1, 2

3. Superior to Alternatives: Albumin has been proven more effective than other volume expanders (dextran, gelatin, hydroxyethyl starch, hypertonic saline) in preventing PICD 2, 3

Dosing Recommendations

For Large-Volume Paracentesis (>5L):

• Standard dose: 8g albumin per liter of ascites removed 1
• Administer immediately after paracentesis completion 4

For Smaller-Volume Paracentesis (<5L):

• Risk of PICD is lower, but albumin is still recommended at the same dose (8g/L) for patients with:
  • Advanced cirrhosis
  • Acute-on-chronic liver failure
  • High risk of post-paracentesis acute kidney injury 1

Evidence for Reduced Dosing

Some evidence suggests that half-dose albumin (4g/L) may be effective in preventing PICD in selected patients:

• A pilot study showed similar PICD rates between standard (8g/L) and half-dose (4g/L) albumin regimens 5
• A standardized order set using graduated dosing (25g for 5-6L, 50g for 7-10L, 75g for >10L) showed no difference in adverse outcomes compared to standard dosing 6

However, these findings should be interpreted cautiously as they come from smaller studies, and major guidelines still recommend the standard 8g/L dose.

Practical Considerations

• Timing: Administer albumin immediately after paracentesis completion 4
• Volume limitation: Consider limiting paracentesis to <8L per session as PICD risk increases with larger volumes 4
• Sterile technique: Perform paracentesis under strict sterile conditions 1
• No need for coagulation testing: Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 1
• Ultrasound guidance: Consider using ultrasound guidance when available to reduce adverse events 1

Post-Paracentesis Management

• Restart diuretics within 1-2 days after paracentesis to prevent rapid reaccumulation of ascites 4
• Maintain low-sodium diet (≤5g/day) 4
• Avoid medications that can worsen ascites or renal function (NSAIDs, ACE inhibitors, angiotensin II antagonists, α1-adrenergic blockers) 1

Common Pitfalls to Avoid

1. Omitting albumin: Failing to administer albumin after large-volume paracentesis significantly increases risk of PICD, renal dysfunction, and mortality 2

2. Substituting with other colloids: Alternative volume expanders are less effective than albumin in preventing PICD 7, 2, 3

3. Delaying albumin administration: Albumin should be given immediately after paracentesis completion 4

4. Inaccurate volume measurement: Underestimating ascites volume can lead to underdosing of albumin 4

5. Multiple small-volume paracenteses: Performing repeated small-volume paracentesis offers no benefits and increases procedure-related complications 4