What are the indications and guidelines for albumin (human albumin) use in the Intensive Care Unit (ICU)?

Indications for Albumin Use in the Intensive Care Unit

Albumin should not be used as first-line volume replacement in critically ill adult patients but is recommended for specific conditions including large-volume paracentesis and spontaneous bacterial peritonitis in cirrhotic patients. 1

General Recommendations for Albumin Use in ICU

• Not recommended for routine volume replacement in critically ill adults, as it shows no mortality benefit compared to crystalloids and is significantly more expensive 1
• Not recommended for treatment of hypoalbuminemia alone as serum albumin concentration does not reflect albumin function 2
• Not recommended for routine use with diuretics for removal of extravascular fluid in critically ill patients 1
• Not recommended for routine use in cardiovascular surgery for priming bypass circuits or volume replacement 1, 2

Evidence-Based Indications for Albumin in ICU

Liver Disease (Strong Evidence)

• Large-volume paracentesis (>5L): Administer 8g albumin per liter of ascites removed using 20-25% albumin solution to prevent post-paracentesis circulatory dysfunction 1, 2
• Spontaneous bacterial peritonitis: Dose at 1.5g albumin/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 2
• Hepatorenal syndrome: Used in combination with vasoconstrictors like terlipressin, though evidence is less definitive than for other liver indications 2

Sepsis and Septic Shock (Conditional Evidence)

• May be considered as second-line therapy when patients require large volumes of crystalloids, per the 2021 Surviving Sepsis Campaign guidelines 1
• Not superior to crystalloids as first-line therapy for mortality reduction or prevention of acute kidney injury 1
• The ALBIOS trial (1,818 patients) showed no improvement in 28-day mortality when albumin was added to crystalloids in severe sepsis 3

Other Potential ICU Indications

• Emergency treatment of hypovolemic shock: As a second-line therapy when crystalloids are insufficient, especially in oncotic deficits or long-standing shock 4
• Burn therapy: May be used beyond 24 hours after thermal injury to maintain plasma colloid osmotic pressure 4
• Adult Respiratory Distress Syndrome (ARDS): May be considered when clinical signs show hypoproteinemia with fluid volume overload 4
• Acute liver failure: May support colloid osmotic pressure and bind excess plasma bilirubin 4

Dosing Considerations

• For volume replacement, total dose should not exceed normal albumin levels (about 2g/kg body weight) in the absence of active bleeding 4
• For large-volume paracentesis: 8g albumin per liter of ascites removed 2
• For spontaneous bacterial peritonitis: 1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3 2

Potential Adverse Effects

• Fluid overload and circulatory overload 4
• Hypotension 4
• Hemodilution requiring RBC transfusion 4
• Anaphylaxis 4
• Peripheral gangrene from dilution of natural anticoagulants 4

Cost Considerations

• Albumin costs approximately $130/25g USD, making it significantly more expensive than crystalloids 2
• Cost-effectiveness should be considered when alternatives exist 2, 5

Common Pitfalls to Avoid

• Administering albumin for hypoalbuminemia alone without a specific indication 2, 6
• Using albumin as first-line fluid for general volume resuscitation 1
• Administering hyperoncotic albumin without adequate hydration in dehydrated patients, which can worsen the condition 4
• Failure to monitor for circulatory overload, especially in patients with cardiac or renal dysfunction 4

Implementation of evidence-based guidelines for albumin use can significantly reduce inappropriate administration and healthcare costs while ensuring patients receive this resource when truly beneficial 5.