What is the recommended protocol for infusing human albumin (HA) in adults with hypoalbuminemia?

How to Infuse Human Albumin

Human albumin should be administered intravenously at specific doses and rates depending on the clinical indication, with 20-25% solutions infused after large-volume paracentesis (>5L) at 8g/L of ascites removed, or 1.5 g/kg within 6 hours followed by 1 g/kg on day 3 for spontaneous bacterial peritonitis with renal dysfunction. 1

Key Principle: Albumin Is Not for Routine Hypoalbuminemia

• Albumin infusion should NOT be used routinely to correct hypoalbuminemia in most clinical settings 1, 2
• The primary approach is treating the underlying cause of low albumin rather than the albumin level itself 2
• Albumin is expensive (~$130/25g USD) and carries risks including fluid overload, hypotension, hemodilution, and anaphylaxis 2

Specific Indications and Infusion Protocols

Large-Volume Paracentesis (>5L)

• Infuse 20% or 25% albumin solution at 8g albumin per liter of ascites removed 1
• Administer after the paracentesis is completed 1
• For paracentesis <5L, consider albumin only in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1
• This is a strong recommendation with high-quality evidence 1

Spontaneous Bacterial Peritonitis (SBP)

• Infuse 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1
• This protocol applies specifically to patients with increased or rising serum creatinine 1
• Important caveat: Standard dose albumin (1.5 g/kg) infused over 6 hours causes symptomatic circulatory overload in most patients, particularly in Indian populations 3
• Consider infusing over a longer duration than 6 hours to improve tolerance, though optimal duration requires further study 3

Administration Technique

Preparation and Compatibility

• Administer via intravenous route only 4
• Use aseptic technique at a non-infected, non-traumatized venipuncture site 4
• Compatible with whole blood, packed red cells, and standard electrolyte/carbohydrate solutions 4
• Do NOT mix with protein hydrolysates, amino acid mixtures, or alcohol-containing solutions 4
• Can be given without regard to recipient blood group 4

Infusion Rate and Monitoring

• The solution is ready to use as contained in the bottle 4
• Monitor closely for circulatory overload during infusion 3
• If respiratory distress develops, stop the infusion immediately and do not restart that particular dose 3
• The next scheduled dose may be started if no respiratory distress is present 3

Concentration Selection

• Use 20% or 25% albumin solutions for most indications in cirrhosis 1
• The oncotic pressure of 25% albumin is approximately four times higher than normal human serum 4
• Plasma volume expansion depends on the amount of albumin given and the plasma volume deficit, not the concentration of the solution 5
• 5% solutions may be preferred in some settings due to lower viscosity and easier infusion 5

Volume Deficit vs. Oncotic Deficit

Volume Deficit Management

• For acute volume deficit, combine albumin with isotonic electrolyte solutions in a ratio of 1:3 or 1:4 (albumin:electrolyte) 4
• Total dose should not exceed the normal circulating albumin mass of 2g per kg body weight in the absence of active hemorrhage 4
• Chronic volume deficits may be treated with albumin alone as a trial 4

Oncotic Deficit Correction

• Calculate dose as: (desired TSP - actual TSP) × plasma volume (~40 mL/kg) × 2 4
• The factor of 2 accounts for the hidden extravascular albumin deficit 4
• Target serum oncotic pressure near 20 mmHg (equivalent to total serum protein of 5.2 g/100 mL) represents a threshold below which complication risk increases 4
• In highly catabolic patients, attempts to raise total serum protein above 6 g/100 mL are usually futile even with massive albumin doses 4

When NOT to Use Albumin

Albumin is NOT recommended for: 1, 2

• Routine volume replacement in critically ill patients (excluding thermal injuries and ARDS)
• First-line treatment of hypoalbuminemia without specific complications
• Intradialytic hypotension prevention or treatment
• Pediatric cardiovascular surgery
• Conjunction with diuretics for extravascular fluid removal
• Preterm neonates with respiratory distress and low albumin
• Routine correction of hypoalbuminemia in hospitalized cirrhosis patients (no improvement in infections, kidney dysfunction, or death) 6

Critical Monitoring Parameters

• Verify effect by measuring post-infusion total serum protein level 4
• Monitor for signs of circulatory overload: respiratory distress, pulmonary edema 3
• Check hemodynamic response to guide dosing in volume deficit 4
• Inspect solution before use: should be clear, slightly viscous, and colorless to amber/green; do not use if turbid or contains particulate matter 4

Common Pitfall

The most significant pitfall is infusing standard doses too rapidly (over 6 hours), which causes symptomatic circulatory overload in the majority of patients 3. Consider slower infusion rates over longer periods, though optimal duration requires validation in clinical trials 3.