Albumin Infusion Protocol for Large Volume Paracentesis
Albumin should be administered after paracentesis is completed, not during the procedure, using 20% or 25% albumin solution at a dose of 6-8 g/L of ascites removed. 1, 2
Dosing Guidelines Based on Volume Removed
- For paracentesis >5 liters, administer 6-8 g albumin per liter of ascites removed 3, 2
- For paracentesis <5 liters, albumin replacement is generally not required as smaller volume removals are not associated with significant hemodynamic changes 2
- 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
- Complete the paracentesis in a single session, draining ascites to dryness as rapidly as possible over 1-4 hours 3
- Infuse albumin after paracentesis is completed, not during the procedure 1
- Use 20% or 25% albumin solution (25% solution contains 25 g of albumin per 100 mL) 1, 2
Clinical Rationale
- Albumin replacement prevents post-paracentesis circulatory dysfunction (PICD), which can lead to serious complications including renal impairment, hepatorenal syndrome, and hyponatremia 3, 1
- Studies show significantly higher rates of renal impairment (11% vs 0%), hyponatremia (6% vs 9%), and activation of the renin-angiotensin-aldosterone system in patients not treated with albumin after large volume paracentesis 3, 4
- PICD occurs in up to 80% of patients in the absence of volume expansion at the time of paracentesis 3
Practical Implementation
- For a typical 6-8 liter paracentesis, administer 36-64 g of albumin (e.g., 144-256 mL of 25% albumin) 3, 2
- A standardized approach using 25 g albumin for 5-6 L removed, 50 g for 7-10 L, and 75 g for >10 L has been shown to be effective 5
- Some evidence suggests that half-doses of albumin (4 g/L) may be effective in preventing PICD with similar outcomes to standard dosing, but this is not yet incorporated into guidelines 6
Monitoring
- Monitor for signs of hyponatremia, renal impairment, and hypotension after the procedure 3, 5
- The drain should not be left in overnight to minimize the risk of infection 3
- After paracentesis, have the patient lie on the opposite side for two hours if there is leakage of any remaining ascitic fluid 3