What is the role of albumin and diuretics in managing sepsis?

Role of Albumin and Diuretics in Managing Sepsis

Crystalloids, not albumin, should be used as first-line fluid therapy in sepsis, while diuretics may be beneficial in the de-escalation phase to achieve negative fluid balance after initial resuscitation. 1, 2

Initial Fluid Resuscitation in Sepsis

First-Line Fluid Choice

• Crystalloids are recommended as the first-line fluid for resuscitation in sepsis 1, 2
  • Balanced/buffered crystalloids (e.g., lactated Ringer's) are preferred over 0.9% saline 1, 2
  • Initial fluid resuscitation should include at least 30 mL/kg of IV crystalloid within the first 3 hours 2
  • Fluid administration should be titrated to clinical markers of cardiac output (heart rate, blood pressure, capillary refill time, level of consciousness, urine output) 1

Role of Albumin

• Albumin is not recommended as first-line therapy for initial resuscitation in sepsis 1, 3
• Consider albumin only when patients require substantial amounts of crystalloids 2
• The evidence does not demonstrate a significant mortality benefit for albumin over crystalloids 3
• Cost considerations further limit albumin's role as a primary resuscitation fluid 1, 3

Special Considerations for Albumin

• In patients with cirrhosis and sepsis-induced hypotension, albumin may provide higher rates of shock reversal and potentially improved short-term survival 1
• However, targeting specific albumin levels may increase risks of pulmonary edema and fluid overload 1
• The Fluid Resuscitation in Sepsis-Induced Hypotension Among Patients With Cirrhosis study showed higher 1-week survival with 5% albumin compared to normal saline (43.5% vs. 38.3%) 1

Fluid Management After Initial Resuscitation

Avoiding Fluid Overload

• After initial resuscitation, a more conservative fluid management approach is recommended 2
• Volume overload is an independent risk factor for morbidity and mortality in sepsis 4
• Achieving negative fluid balance during treatment is associated with better outcomes 4

Role of Diuretics (Dytor)

• Diuretics become important in the de-escalation phase after initial resuscitation
• They help achieve negative fluid balance when signs of fluid overload develop 4
• Signs of fluid overload that should prompt diuretic use include:
  • Clinical signs of pulmonary edema
  • New or worsening hepatomegaly
  • Peripheral edema 1, 2

Monitoring During Fluid Management

Hemodynamic Assessment

• Frequent reassessment of clinical markers is essential during both fluid administration and diuresis 1, 2
• Monitor:
  • Mean arterial pressure (target ≥65 mmHg)
  • Urine output (target >0.5 mL/kg/hr)
  • Serial blood lactate measurements
  • Advanced hemodynamic variables when available (cardiac output/index, systemic vascular resistance) 1, 2

Fluid Responsiveness

• Dynamic variables such as pulse pressure variation and stroke volume variation should guide further fluid administration 2
• Echocardiography can assess cardiac function, volume status, and response to fluid challenges 2

Pitfalls and Caveats

1. Avoid excessive fluid administration after the initial resuscitation phase, as it may worsen outcomes 4
2. Don't delay starting vasopressors when indicated (norepinephrine is first-line) for persistent hypotension despite adequate fluid resuscitation 2
3. Don't use albumin routinely as a first-line resuscitation fluid due to lack of proven mortality benefit and higher cost compared to crystalloids 1, 3
4. Don't use starches for fluid resuscitation in sepsis (strong recommendation against) 1
5. Don't use albumin to target specific serum albumin levels, as this may increase risk of pulmonary edema and fluid overload 1
6. Don't forget to reassess fluid status frequently during both resuscitation and de-escalation phases 1, 2