Guidelines for Albumin (Alamin) Injection in Volume Expansion and Shock Treatment
Isotonic crystalloids should be used as first-line therapy for volume expansion in most patients at risk for or with acute kidney injury, while albumin should be reserved for specific clinical scenarios where its benefits outweigh potential risks. 1
General Recommendations for Albumin Use
Albumin is not recommended as first-line treatment for volume expansion in most clinical scenarios, with crystalloid solutions being preferred due to similar efficacy, lower cost, and fewer potential adverse effects 1
In the absence of hemorrhagic shock, isotonic crystalloids rather than colloids (including albumin) are suggested as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI (KDIGO recommendation 3.1.1, Grade 2B) 1
Albumin resuscitation has been associated with harm in patients with traumatic brain injury and should be avoided in that setting 1
Specific Indications for Albumin Use
FDA-Approved Indications
Emergency treatment of hypovolemic shock: Albumin 25% (Plasbumin-25) is hyperoncotic and will expand plasma volume by three to four times the volume administered by withdrawing fluid from interstitial spaces 2
The total dose should not exceed the level of albumin found in the normal individual (approximately 2 g per kg body weight) in the absence of active bleeding 2
For patients with dehydration, additional crystalloids must be given, or alternatively, Albumin 5% should be used 2
Liver Disease
Intravenous albumin administration is beneficial for prevention of renal failure and death in patients with:
- Spontaneous bacterial peritonitis
- Large-volume paracentesis 1
For hepatorenal syndrome, diagnostic criteria include lack of improvement in renal function after volume expansion with albumin (1 g/kg/d up to 100 g/d) for at least 2 days and withdrawal of diuretic therapy 1
Other Indications
Burns: After 24 hours post-burn injury, albumin can be used to maintain plasma colloid osmotic pressure with aim to maintain plasma albumin concentration around 2.5 ± 0.5 g per 100 mL 2
Hypoproteinemia: Treatment with albumin may be valuable during major surgery when patients can lose over half of their circulating albumin, or in sepsis/intensive care patients 2
Neonatal hemolytic disease: Administration of albumin may be indicated prior to exchange transfusion (1 g/kg body weight given about 1 hour prior) to bind free bilirubin, reducing risk of kernicterus 2
Albumin in Septic Shock
In comparison with crystalloids, it is probably not recommended in cases of sepsis or septic shock to use albumin as first-line treatment to reduce mortality or renal replacement therapy requirement (Grade 2-) 1
While some studies showed improved circulatory function and lower volume requirements with albumin in septic shock, no definitive mortality benefit has been demonstrated 1
Albumin in Hemorrhagic Shock
There has been no published study specifically focusing on the benefit of albumin during hemorrhage, and the few studies based on sub-group analysis of trauma patients without traumatic brain injury showed no benefit 1
In patients with hemorrhagic shock, it is recommended to use balanced crystalloids rather than 0.9% NaCl as first-line fluid therapy to reduce mortality and/or adverse renal events (Grade 2+) 1
In children with severe malaria presenting with coma and features of shock, human albumin solution may be considered the resuscitation fluid of choice 1
Administration Guidelines
Albumin should always be administered by intravenous infusion, either undiluted or diluted in 0.9% Sodium Chloride or 5% Dextrose in Water 2
For patients requiring sodium restriction, albumin should only be administered either undiluted or diluted in a sodium-free carbohydrate solution such as 5% Dextrose in Water 2
In hypoproteinemic patients with approximately normal blood volumes, the rate of administration should not exceed 2 mL per minute, as more rapid injection may precipitate circulatory embarrassment and pulmonary edema 2
Precautions and Monitoring
Patients should always be monitored carefully to guard against circulatory overload 2
Since albumin is hyperoncotic, in the presence of dehydration, it must be given with or followed by additional fluids 2
In hemorrhage, the administration of albumin should be supplemented by transfusion of whole blood to treat relative anemia associated with hemodilution 2
The rapid rise in blood pressure following administration of a colloid with positive oncotic activity necessitates careful observation to detect and treat severed blood vessels that may not have bled at lower blood pressure 2
Volume expansion with albumin 20% causes a secondary fluid resorption with maximal effect at 30 minutes, but the effect decreases significantly faster in septic patients than in healthy controls 3