What alternative measures, such as albumin, can be used to support blood pressure in a patient who is at the ceiling of care and cannot receive pressors (vasopressors)?

Alternative Measures for Blood Pressure Support in Patients at Ceiling of Care

For patients at ceiling of care who cannot receive vasopressors, albumin administration is recommended for blood pressure support, particularly in cases of hypovolemia, but should be used cautiously due to potential risks and limited evidence for efficacy.

Albumin for Blood Pressure Support

• Albumin can be used for blood pressure support in patients who cannot receive vasopressors, particularly in cases of hypovolemia, as it expands plasma volume by three to four times the volume administered by withdrawing fluid from interstitial spaces 1
• Hyperoncotic albumin (25%) may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed 1
• Albumin is indicated for emergency treatment of hypovolemic shock when the patient is normally hydrated interstitially or has interstitial edema 1
• If the patient is dehydrated, additional crystalloids must be given along with albumin 1

Considerations for Albumin Administration

• The total dose of albumin should not exceed the level found in normal individuals (about 2 g per kg body weight) in the absence of active bleeding 1
• Patient's hemodynamic response should be monitored with usual precautions against circulatory overload 1
• Albumin may be particularly beneficial in patients with low serum albumin levels who require kidney replacement therapy, as hypoalbuminemia is strongly associated with hypotension 2
• Paradoxical hypotension can occur with rapid infusion of albumin (11% of cases in one study), particularly in patients taking ACE inhibitors 3

Volume Management Strategies

• Careful attention must be paid to fluid resuscitation and maintenance of adequate intravascular volume in patients with compromised hemodynamics 4
• For fluid replacement, colloid solutions (such as albumin) are preferred over crystalloid solutions in patients with liver failure 4
• All solutions should contain dextrose to maintain euglycemia in patients with liver failure 4
• Volume control with loop diuretics may be needed in patients with advanced CKD with signs of volume overload and in patients with nephrotic-range proteinuria 4

Non-Pharmacological Approaches

• Device-guided breathing techniques can be considered as an adjunctive method to help lower blood pressure (Class IIA, Level of Evidence B) 5
• Exercise-based regimens, including aerobic (Class I, Level of Evidence A) and dynamic resistance (Class IIA, Level of Evidence B) modalities, have relatively strong supporting evidence for blood pressure control 5
• Isometric handgrip exercises may provide modest blood pressure reduction (Class IIB, Level of Evidence C) 5

Special Considerations for Specific Patient Populations

Patients with Cirrhosis

• Patients with cirrhosis have total extracellular fluid overload but central effective circulating hypovolemia 6
• Albumin may be effective in preventing hemodynamic derangements associated with large-volume paracentesis and in preventing renal failure during spontaneous bacterial peritonitis 6
• In association with splanchnic vasopressors, albumin may be beneficial in caring for patients with hepatorenal syndrome 6

Patients with Kidney Disease

• In patients with kidney disease requiring dialysis, albumin may be of value in the treatment of shock or hypotension 1
• The usual volume administered is about 100 mL, taking particular care to avoid fluid overload as these patients are often fluid overloaded and cannot tolerate substantial volumes of salt solution 1
• If dialysis support is needed for acute renal failure, a continuous mode rather than an intermittent mode is recommended 4

Monitoring and Assessment

• Pulmonary artery catheterization should be considered in hemodynamically unstable patients to ensure appropriate volume replacement 4
• Monitoring for signs of adequate perfusion, including mental status, capillary refill, lactate clearance, and urine output, is recommended 7
• The initial selection of an antihypertensive agent should be based on an assessment of potential risks and benefits, particularly in patients with advanced CKD 4

Pitfalls and Caveats

• Despite its theoretical benefits, clinical trials have demonstrated that albumin administration is not as effective a volume expander as might be assumed based on its oncotic properties 2
• Albumin is expensive and there are minimal data supporting its routine use during kidney replacement therapy 2
• Some studies suggest that hyperoncotic albumin solutions may precipitate or worsen acute kidney injury in patients with sepsis or shock, though overall evidence supporting this effect is weak 2
• Avoid relying solely on fluid resuscitation in profound shock as this may prolong hypotension and worsen outcomes 7