Albumin Administration for Patients on Norepinephrine (Levophed)
Albumin should NOT be routinely administered to patients solely because they are on norepinephrine (Levophed), as there is no evidence supporting this practice for improving outcomes in most clinical scenarios.
Understanding Norepinephrine and Volume Status
- Norepinephrine (Levophed) is contraindicated in patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed 1
- Continuous administration of norepinephrine without addressing blood volume replacement can lead to severe peripheral and visceral vasoconstriction, decreased renal perfusion, poor systemic blood flow, tissue hypoxia, and lactate acidosis 1
- Blood volume depletion should always be corrected as fully as possible before or concurrently with vasopressor administration 1
Specific Clinical Scenarios Where Albumin Is Indicated
Cirrhosis-Related Conditions
- Albumin is recommended for large-volume paracentesis (LVP) at a dose of 8 g/L of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction 2
- For paracentesis of >5 L of ascites, albumin is more effective than other plasma expanders in preventing circulatory dysfunction 2
- IV albumin is indicated in patients with spontaneous bacterial peritonitis to prevent renal failure and reduce mortality 2, 3
- Albumin is the volume expander of choice in hospitalized patients with cirrhosis and ascites presenting with acute kidney injury 2
Hepatorenal Syndrome
- For hepatorenal syndrome with acute kidney injury (HRS-AKI), terlipressin is the vasoactive drug of choice, and concurrent albumin can be considered based on the patient's volume status 2
- Norepinephrine can be used in the treatment of HRS-AKI, but albumin administration should be guided by the patient's volume status rather than automatically given 2
When Albumin Should NOT Be Used
- Albumin should not be used in patients with cirrhosis and uncomplicated ascites 2
- Vasoconstrictors (including norepinephrine) should not be used in the management of uncomplicated ascites, after large-volume paracentesis, or in patients with spontaneous bacterial peritonitis 2
- 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 3
- Albumin resuscitation has been associated with harm in patients with traumatic brain injury and should be avoided in that setting 3
Volume Resuscitation in Patients on Norepinephrine
- For patients on norepinephrine requiring volume expansion, isotonic crystalloids should be used as first-line therapy in most cases 3
- Whole blood or plasma, if indicated to increase blood volume in patients on norepinephrine, should be administered separately from the vasopressor infusion 1
- In patients with septic shock, there is no demonstrated mortality benefit of albumin over crystalloids, despite some studies showing improved circulatory function 3
Monitoring and Management Approach
- For patients on norepinephrine, continuously monitor blood pressure, urine output, and tissue perfusion 1
- If a patient on norepinephrine shows signs of hypovolemia, address volume replacement first, preferably with crystalloids in most cases 3, 1
- For patients with cirrhosis on norepinephrine, consider albumin only if they have specific indications such as HRS-AKI, large-volume paracentesis, or spontaneous bacterial peritonitis 2
Potential Risks of Inappropriate Albumin Use
- Albumin administration is costly without demonstrated benefit in many clinical scenarios 4
- In some critically ill patients, albumin administration has been associated with pulmonary edema 2
- Hyperoncotic albumin solutions may potentially worsen acute kidney injury in some patients with sepsis or shock 5
Remember that the primary goal in patients on norepinephrine is to address the underlying cause of hypotension and ensure adequate volume status, but albumin should be reserved for specific clinical scenarios where its benefits are proven rather than used routinely.