What is the role of albumin plus Dytor (torsemide) in managing sepsis?

Role of Albumin Plus Torsemide (Dytor) in Sepsis Management

There is insufficient evidence to recommend the routine use of albumin plus torsemide (Dytor) combination therapy in sepsis management, as crystalloids remain the first-line fluid for resuscitation with albumin reserved only for patients requiring large volumes of crystalloids. 1

Initial Fluid Management in Sepsis

• Crystalloids are the first-line fluid therapy for sepsis resuscitation:

  • Initial fluid resuscitation with at least 30 mL/kg of IV crystalloid within the first 3 hours is recommended 2
  • Balanced crystalloids (e.g., lactated Ringer's) are preferred over normal saline due to potential mortality benefits 1

• Albumin's role is limited and conditional:

  • The Surviving Sepsis Campaign guidelines (2021) recommend albumin only as an addition to crystalloids when patients require large volumes of crystalloids (Weak Recommendation, Moderate-Quality Evidence) 1
  • The lack of proven mortality benefit and higher cost of albumin compared to crystalloids supports crystalloids as first-line therapy 1

Evidence on Albumin in Sepsis

• The ALBIOS trial (2014) showed that in patients with severe sepsis, albumin replacement in addition to crystalloids did not improve survival rates at 28 and 90 days compared to crystalloids alone 3

• While some studies suggest albumin may have theoretical benefits including:

  • Higher rates of shock reversal 1
  • Antioxidant effects and positive effects on vessel wall integrity 4
  • Potential to preserve renal function in critically ill patients 4

• However, these potential benefits have not consistently translated to improved mortality outcomes in large trials 1, 3

Albumin Plus Diuretics (Including Torsemide)

• For the specific combination of albumin plus loop diuretics (such as torsemide):
  • A 2014 systematic review found that while albumin with furosemide increased urine output at 6 hours compared to furosemide alone in patients with hypoalbuminemia and hypervolemia, there was no difference in urine output at 24 hours 1
  • Another systematic review evaluating albumin with diuretics versus diuretics alone in mechanically ventilated patients found albumin reduced hypotensive episodes but did not improve mortality or shorten mechanical ventilation duration 1

Potential Risks and Considerations

• Targeting specific albumin levels may be associated with pulmonary edema and fluid overload 1
• Albumin administration in cirrhosis patients with sepsis-induced hypotension showed increased pulmonary complications in one study 1
• Excessive fluid administration can lead to pulmonary edema, abdominal compartment syndrome, prolonged mechanical ventilation, and increased mortality 2

Practical Approach to Fluid Management in Sepsis

1. Begin with balanced crystalloids for initial resuscitation (30 mL/kg within first 3 hours)
2. Assess fluid responsiveness using dynamic variables (pulse pressure variation, stroke volume variation, IVC ultrasound)
3. Consider albumin only when large volumes of crystalloids are required
4. If diuresis is needed later in management:
   • Loop diuretics (including torsemide) may be used
   • Adding albumin to diuretics may increase short-term urine output but has not shown consistent benefits for longer-term outcomes or mortality

Monitoring Response

• Target mean arterial pressure ≥65 mmHg 1, 2
• Monitor urine output (target >0.5 mL/kg/hr) 2
• Assess for signs of fluid overload (pulmonary edema, peripheral edema)
• Frequently reassess hemodynamic status after fluid administration 2

The evidence does not support routine use of albumin plus torsemide (Dytor) combination therapy in sepsis, though this combination might be considered in specific scenarios such as patients with hypoalbuminemia requiring diuresis after initial fluid resuscitation.