When is albumin infusion indicated in critically ill patients?

Albumin Infusion in Critically Ill Patients

Albumin infusion is not recommended for routine volume replacement in critically ill patients as it shows no mortality benefit compared to crystalloids and should be reserved for specific indications such as cirrhosis with large-volume paracentesis or spontaneous bacterial peritonitis. 1

General Recommendations for Critically Ill Patients

• Albumin should not be used routinely for volume resuscitation in critically ill adult patients as substantial evidence from randomized controlled trials shows no mortality benefit compared to crystalloids 1
• Multiple systematic reviews, including a 2018 Cochrane review of 20 studies (N=13,047), found no difference in mortality between albumin and crystalloids in ICU patients (RR 0.98; 95% CI 0.92-1.06) 1
• The largest trial (SAFE study) with 6,997 critically ill patients showed no difference in 28-day mortality between 4% albumin and normal saline (RR 0.99; 95% CI 0.91-1.09) 1
• Albumin is significantly more expensive than crystalloid alternatives, making it a poor first-line choice for general volume resuscitation 2

Specific Situations Where Albumin Should Be Avoided

• Albumin should be avoided in patients with traumatic brain injury, as it was associated with higher mortality (RR 1.62; 95% CI 1.12-2.34) in this population 1
• A 2015 systematic review found higher mortality in trauma patients receiving albumin compared to crystalloids (RR 1.35; 95% CI 1.03-1.77) 1
• Albumin is not recommended for treatment of hypoalbuminemia alone, as this does not improve clinical outcomes 3, 4
• Albumin is not recommended for routine use in cardiovascular surgery 3

Specific Indications Where Albumin May Be Considered

• Albumin is recommended for patients with cirrhosis undergoing large-volume paracentesis (>5 liters), administered at 8g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction 3
• For spontaneous bacterial peritonitis, albumin should be administered at 1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3, which has been shown to reduce renal dysfunction and mortality 3
• The 2021 Surviving Sepsis Campaign suggests using albumin in addition to crystalloids only in sepsis and septic shock patients requiring large volumes of crystalloids (Weak Recommendation, Moderate-Quality Evidence) 1, 2

Albumin Formulations and Administration

• Two main concentrations are used clinically: 4-5% (iso-oncotic) and 20-25% (hyperoncotic) albumin solutions 2
• 20% albumin has shown greater benefits for cardiovascular function and requires lower infusion volumes compared to 4-5% solutions 2
• In the SAFE study, 4% albumin was associated with lower volume requirements compared to crystalloids (3011 ± 1924 vs. 3522 ± 2507 mL, p < 0.001) 2

Special Considerations

• Hypoalbuminemia may act as an effect moderator in volume resuscitation, with albumin potentially being more effective when serum albumin levels are low (<25 g/L), though this doesn't translate to improved mortality 5, 6
• In hemodialysis patients, 25% albumin may improve hypotension and ultrafiltration rates compared to saline 2
• Potential adverse effects of albumin infusion include fluid overload, hypotension, hemodilution requiring RBC transfusion, and anaphylaxis 3

Current Evidence Gaps

• Several large randomized trials are ongoing to further evaluate albumin's role in specific conditions, including septic shock, high-risk cardiac surgery, and acute kidney injury requiring kidney replacement therapy 1
• The International Collaboration for Transfusion Medicine Guidelines (ICTMG) notes that most recommendations regarding albumin use are conditional based on low- or very low-quality evidence, highlighting the need for additional research 1