What is the recommended protocol for albumin 20% (human albumin) infusion?

Albumin 20% Infusion Protocol

Albumin 20% should be administered according to specific clinical indications with dosing protocols that vary by condition, primarily for cirrhosis-related complications including large-volume paracentesis (8g/L of ascites removed), spontaneous bacterial peritonitis (1.5g/kg then 1g/kg on day 3), and hypovolemic shock, but should NOT be used routinely for general volume resuscitation or hypoalbuminemia correction alone. 1, 2

Evidence-Based Indications and Dosing Protocols

Large-Volume Paracentesis

• Administer 8g albumin per liter of ascites removed when >5L is drained 1, 2, 3
• Infuse after paracentesis is completed using 20% or 25% albumin solution 1, 2
• This prevents post-paracentesis circulatory dysfunction and subsequent renal impairment 1, 2

Spontaneous Bacterial Peritonitis (SBP)

• For patients with increased or rising serum creatinine:
  • 1.5g albumin/kg within 6 hours of diagnosis 1, 2
  • Followed by 1g/kg on day 3 1, 2
• Use estimated dry weight for dosing calculations (though this can be challenging in cirrhotic patients) 1, 2
• This protocol reduces renal dysfunction risk by 72% and mortality by 47% 1, 2
• Caution: Doses exceeding 87.5g (>4×100mL of 20% albumin) may be associated with worse outcomes due to fluid overload 1

Hypovolemic Shock

• Albumin 20% is hyperoncotic and expands plasma volume by 3-4 times the infused volume by recruiting interstitial fluid 3, 4
• Total dose should not exceed 2g/kg body weight in the absence of active bleeding 3
• The patient must be normally hydrated interstitially or have interstitial edema; if dehydrated, additional crystalloids are required 3
• Maximum plasma volume expansion occurs approximately 20 minutes after completing the infusion 4, 5

Burn Therapy

• Beyond 24 hours post-burn, albumin 20% can maintain plasma colloid osmotic pressure after initial crystalloid resuscitation 3

Infusion Rate Considerations

Fast vs. Slow Administration

• Fast infusion (30 minutes) provides 69% larger plasma volume expansion during the first 2 hours compared to slow infusion (120 minutes) 5
• The intravascular half-life of albumin is longer with fast infusion (8.0h vs 6.3h) 5
• No disadvantages were found with the higher infusion rate in healthy volunteers 5
• For clinical protocols being studied: 100mL of 20% albumin every 12 hours for 4 days in community-acquired pneumonia 1

Critical Safety Considerations

Fluid Overload Risk

• Monitor closely for pulmonary complications, particularly in critically ill patients 6
• In a trial comparing 20% albumin to plasmalyte in cirrhotic patients with sepsis, albumin had to be discontinued in 22% of patients due to adverse effects (primarily pulmonary complications) 6
• Fluid overload has been reported in prospective studies of albumin in cirrhosis patients with infection 1

Retention and Capillary Leak

• In septic patients, only 68.5% of infused albumin remains intravascular at 4 hours (compared to 79% in healthy controls) 7
• Serum albumin concentrations decrease significantly faster in septic patients than in healthy controls 7
• The recruited interstitial fluid amounts to approximately 3.4mL for each infused mL of 20% albumin 4

Situations Where Albumin 20% is NOT Recommended

The International Collaboration for Transfusion Medicine Guidelines explicitly advises against albumin use in: 1

• Routine volume resuscitation in critically ill neonatal, pediatric, or adult patients
• Intradialytic hypotension
• Routine cardiovascular surgery
• Treatment of hypoalbuminemia alone in hospitalized cirrhotic patients
• Extraperitoneal infections in cirrhosis

Specific Contraindications from FDA Labeling

• Chronic nephrosis (albumin is promptly excreted with no relief of edema) 3
• Chronic cirrhosis, malabsorption, protein-losing enteropathies as a source of protein nutrition 3

Monitoring Requirements

Hemodynamic Monitoring

• Monitor mean arterial pressure (MAP) - target >65 mmHg in septic shock 6
• Track arterial lactate clearance as a marker of tissue perfusion 6
• Observe for signs of circulatory overload throughout infusion 3

Laboratory Monitoring

• Serial serum albumin levels to guide ongoing dosing 8
• Renal function (creatinine) particularly in SBP patients 1, 2
• Hematocrit for hemodilution assessment 7

Common Pitfalls to Avoid

1. Do not use albumin to "correct" low serum albumin levels alone - this is not evidence-based and wastes resources 1, 2
2. Avoid excessive dosing in SBP - doses >87.5g may cause fluid overload 1
3. Do not assume albumin improves survival in all septic patients - the ALPS trial showed no 28-day mortality benefit despite faster hemodynamic improvement 6
4. Monitor for pulmonary edema closely - this is the most common reason for treatment discontinuation 6
5. Ensure adequate interstitial hydration before using 20% albumin for shock, or use 5% albumin instead 3