What is the recommended protocol for infusing albumin (human albumin) during large volume paracentesis?

Albumin Infusion Protocol for Large Volume Paracentesis

For large volume paracentesis (>5 liters), albumin should be infused after the procedure is completed at a dose of 8 g albumin per liter of ascites removed, using 20% or 25% albumin solution. 1, 2

Dosing Guidelines

• For paracentesis >5 liters: Administer 8 g albumin per liter of ascites removed (e.g., 100 ml of 20% albumin per 3 liters of ascites) 1
• For paracentesis <5 liters: Albumin replacement is generally not required for uncomplicated ascites; synthetic plasma expanders can be used instead 1
• For high-risk patients (those with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury): Consider albumin replacement at 8 g/L even for volumes <5 liters 1, 2

Administration Protocol

• Use 20% or 25% albumin solution (25% solution contains 25 g albumin per 100 mL) 2
• Infuse albumin after paracentesis is completed, not during the procedure 1
• Complete the paracentesis in a single session, draining ascites to dryness as rapidly as possible over 1-4 hours 1
• Perform the entire procedure under strict sterile conditions 1

Clinical Rationale

• Albumin replacement prevents post-paracentesis circulatory dysfunction (PICD), which can lead to serious complications including: 2

  • Renal impairment and hepatorenal syndrome
  • Dilutional hyponatremia
  • Hepatic encephalopathy
  • Increased mortality

• Studies show significantly higher rates of renal impairment, hyponatremia, and activation of the renin-angiotensin-aldosterone system in patients not treated with albumin after large volume paracentesis 1

Special Considerations

• For patients with spontaneous bacterial peritonitis (SBP), use a different dosing regimen: 1.5 g albumin/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 1, 2
• The risk of PICD increases with >8 L of fluid evacuated in a single session 2
• While some studies have investigated using half-doses of albumin (4 g/L), current guidelines still strongly recommend the standard 8 g/L dose 3, 1
• Synthetic plasma expanders (dextran, gelatin, hydroxyethyl starch) are less effective than albumin in preventing PICD and hyponatremia 4, 1

Procedure Technique

• Insert the needle into the left (preferably) or right lower abdominal quadrant using the "Z" track technique 1
• Use a cannula with multiple side perforations to prevent blockage by bowel wall 1
• After paracentesis, have the patient lie on the opposite side for two hours if there is leakage of remaining ascitic fluid 1
• Consider placing a purse-string suture around the drainage site to minimize risk of ascitic fluid leakage 1

Monitoring

• Monitor for signs of renal impairment, hyponatremia, and hypotension following the procedure 5
• The drain should not be left in overnight 1
• Ultrasound guidance should be considered when available to reduce the risk of adverse events 1