Albumin and Furosemide Push-Pull Protocol for Fluid Management
The albumin and furosemide push-pull protocol involves administering intravenous albumin followed by furosemide to enhance diuresis while maintaining hemodynamic stability in patients requiring fluid management. This approach is particularly useful in patients with hypoalbuminemia who may have reduced response to diuretics alone.
Protocol Components
Albumin Administration
- Administer 25% albumin intravenously at a dose of 0.5-1 g/kg (typically 100 ml of 25% albumin) 1
- Infuse albumin slowly to prevent potential cardiac overload, especially in patients with preexisting cardiomyopathy 1
- Albumin infusion should be completed before administering furosemide 2
Furosemide Administration
- Administer furosemide 0.5-2 mg/kg intravenously after albumin infusion 1
- Inject furosemide slowly (over 1-2 minutes) to avoid ototoxicity 3
- For continuous infusion, do not exceed a rate of 4 mg/min 3
Timing Considerations
- Allow 1-2 hours between albumin administration and furosemide to optimize intravascular volume expansion 1, 2
- Furosemide should be administered within 2 hours following albumin infusion for optimal effect 2
Patient Monitoring
Hemodynamic Parameters
- Monitor central venous pressure (CVP) if available; maintain CVP above 3 cm H₂O 4
- Assess for signs of hypovolemia: tachycardia, hypotension, prolonged capillary refill time 5
- Evaluate for signs of fluid overload: pulmonary crackles, increased jugular venous pressure 5
Laboratory Monitoring
- Monitor serum electrolytes, particularly sodium and potassium 1
- Track serum creatinine and BUN to assess kidney function 4
- Monitor serum albumin levels 6
Response Assessment
- Measure urine output hourly to assess diuretic response 7
- Target urine output of at least 0.5-1 mL/kg/hour 4
- Evaluate net fluid balance every 6-24 hours 7
Dosage Adjustments
Albumin Dose Adjustment
- Albumin requirements vary significantly between patients (40-600g) and may need daily adjustment 4
- Higher doses may be required in patients with severe hypoalbuminemia (serum albumin <2.5 g/dL) 6
Furosemide Dose Adjustment
- If diuresis is inadequate after initial dose, increase furosemide by 20 mg increments 3
- Maximum furosemide dose should not exceed 10 mg/kg/day 1
- Consider continuous infusion if bolus doses are ineffective 3
Special Considerations
Contraindications
- Use caution in patients with severe heart failure due to risk of volume overload 1
- Avoid in patients with anuria (furosemide must be stopped in case of anuria) 1
Precautions
- Monitor for signs of electrolyte imbalances, particularly hypokalemia 1
- High doses of furosemide (>6 mg/kg/day) should not be given for periods longer than 1 week 1
- Administer furosemide infusions over 5-30 minutes to avoid hearing loss 1
Evidence of Efficacy
Short-term Benefits
- The combination of albumin and furosemide shows superior short-term efficacy (within 6 hours) compared to furosemide alone in hypoalbuminemic patients 6
- Enhanced water and sodium diuresis is observed in the first 6 hours after combined therapy 6
Long-term Outcomes
- At 24 hours, the difference in diuretic effect between combined therapy and furosemide alone may diminish 6
- Some studies show no significant difference in urine output at 24 and 48 hours between furosemide alone versus furosemide with albumin 7
Clinical Applications
Recommended Clinical Scenarios
- Hypoalbuminemic patients with edema and poor response to diuretics alone 6
- Patients with congenital nephrotic syndrome requiring fluid management 1
- Patients with hepatorenal syndrome and ascites 4