What is the role of albumin in managing non-resolving septic shock?

Role of Albumin in Non-Resolving Septic Shock

Albumin should be considered in patients with septic shock who have worsening shock and require significant amounts of fluid resuscitation, but it should not be routinely used as a first-line resuscitation fluid. 1

Initial Fluid Resuscitation Approach

Initial fluid resuscitation in septic shock should follow these principles:

1. First-line fluid choice: Balanced crystalloids (e.g., lactated Ringer's) are recommended as the initial resuscitation fluid 1

   • Administer at least 30 mL/kg of crystalloids within the first 3 hours 1, 2
   • Continue fluid administration as long as hemodynamic improvement is observed 1

2. When to consider albumin:

   • After large volumes of crystalloids have been administered 1
   • In patients with worsening shock despite adequate crystalloid resuscitation 1
   • In patients with cirrhosis and sepsis-induced hypotension (higher rates of shock reversal and potentially improved short-term survival) 1

Evidence for Albumin Use in Septic Shock

Benefits of Albumin

• In patients with sepsis and septic shock, albumin administration may:
  • Provide better hemodynamic stability with higher mean arterial pressure 3
  • Result in lower net fluid balance compared to crystalloids alone 3
  • Reduce systemic inflammation and circulatory dysfunction, particularly in patients with cirrhosis 1
  • Potentially shorten duration of vasopressors in patients with more severe sepsis 1

Limitations and Considerations

• Mortality benefit unclear: The ALBIOS trial (n=1818) showed no significant difference in 28-day mortality between albumin plus crystalloids versus crystalloids alone (31.8% vs. 32.0%) 3

• Patient-specific factors: Recent data suggests albumin use in septic shock is associated with:

  • Gastrointestinal focus of infection
  • Higher doses of norepinephrine at baseline 4
  • Significant practice variation between treatment centers 4

• Potential adverse effects:

  • Pulmonary complications and fluid overload, particularly when targeting specific serum albumin levels 1
  • No clear benefit in vasopressor-free days in patients with hypoalbuminemia 5

Practical Algorithm for Albumin Use in Non-Resolving Septic Shock

1. Initial resuscitation: Begin with balanced crystalloids (30 mL/kg) 1, 2

2. Assess response: Monitor hemodynamic parameters (MAP, heart rate, urine output, lactate clearance)

3. Consider albumin in these specific scenarios:

   • Persistent shock despite adequate crystalloid resuscitation
   • When large volumes of crystalloids have already been administered
   • Patients with cirrhosis and sepsis-induced hypotension 1
   • Patients requiring high-dose vasopressors 4

4. Administration approach:

   • For resuscitation: 5% albumin solution may be preferred 1
   • For oncotic support: 20-25% albumin may be considered 6
   • Avoid targeting specific serum albumin levels due to risk of pulmonary edema 1

5. Monitor for complications:

   • Pulmonary edema
   • Fluid overload
   • Circulatory overload

Special Considerations

• Patients with cirrhosis: Two single-center RCTs showed albumin provided higher rates of shock reversal in patients with cirrhosis and sepsis-induced hypotension 1

• Vasopressor management: Target a MAP of 65 mmHg, with norepinephrine as first-line vasopressor 1

• Fluid balance: Albumin may help achieve a negative fluid balance in patients with hypoalbuminemia and conditions associated with edema 7

• Renal function: Albumin may have potential to preserve renal function compared to artificial colloids, though evidence is limited 7

The decision to use albumin in non-resolving septic shock should be guided by the patient's response to initial crystalloid resuscitation, underlying conditions (particularly cirrhosis), and the need for ongoing fluid resuscitation with consideration of the risk-benefit profile.