What is the role of 20% albumin in Intensive Care Unit (ICU) settings?

Role of 20% Albumin in the ICU

Current evidence does not support routine use of 20% albumin for general volume resuscitation in ICU patients, but it has specific, well-defined roles in cirrhotic patients and may offer benefits in septic shock requiring large-volume resuscitation, though guidelines cannot yet make a firm recommendation for the latter. 1, 2

Evidence-Based Indications for 20% Albumin

Cirrhosis-Related Indications (Strong Evidence)

Large-Volume Paracentesis:

• Administer 8g of 20% albumin per liter of ascites removed when removing >5 liters to prevent post-paracentesis circulatory dysfunction, which leads to renal impairment 1, 2
• Infuse after paracentesis completion using 20% or 25% albumin solution 2

Spontaneous Bacterial Peritonitis:

• Dose: 1.5g/kg within 6 hours of diagnosis, followed by 1.0g/kg on day 3 1, 2
• This regimen reduces renal dysfunction risk by 72% and mortality by 47% 2
• Dosing based on estimated dry weight 2

Hepatorenal Syndrome:

• Use in combination with vasoconstrictors (terlipressin) for improved outcomes 2

Septic Shock (Emerging but Equivocal Evidence)

Potential Benefits:

• The ALBIOS trial showed a mortality benefit in the septic shock subgroup (OR 0.87,95% CI 0.77-0.99) when 20% albumin was used to maintain elevated serum albumin levels 1
• One meta-analysis found 90-day mortality benefit in septic shock (OR 0.81,95% CI 0.67-0.97) 1
• In cirrhotic patients with sepsis-induced hypotension, 20% albumin achieved faster reversal of hypotension compared to crystalloids 3

Physiological Advantages:

• Lower cardiovascular SOFA scores (1.20 vs 1.42, p=0.03) 1
• Shorter duration of vasopressor treatment (3 vs 4 days, p=0.007) 1
• Lower fluid balance at days 2-4 1
• Lower total infused fluid volumes (3011 mL vs 3522 mL, p<0.001) 1
• Volume expansion equivalent to 430 mL with 200 mL of 20% albumin 4

Critical Limitations:

• The ALBIOS trial had lower-than-predicted mortality (30% vs 45% predicted) and was underpowered 1
• Five of six meta-analyses found no mortality benefit with either 4-5% or 20% albumin 1
• Expert consensus: insufficient evidence to make a formal recommendation for albumin use in sepsis/septic shock despite physiological benefits 1

Where 20% Albumin is NOT Recommended

General ICU Volume Resuscitation:

• Not recommended for routine volume replacement in critically ill adults, as it is not superior to crystalloids for general resuscitation 1, 2

Cardiovascular Surgery:

• Not recommended for routine use; the largest trial (1,386 patients) showed increased bleeding, resternotomy, and infection rates with albumin 1, 2

Hypoalbuminemia Alone:

• Not indicated for treatment of low serum albumin without other specific indications, as serum concentration does not reflect albumin function 2

Traumatic Brain Injury:

• Associated with significantly higher mortality; cannot be recommended 5

Pediatric Critical Care:

• A large trial in children with febrile illness and hypoperfusion found excess mortality with albumin bolus strategy 1

Hypoalbuminemia as an Effect Moderator

Evidence for Enhanced Effectiveness in Hypoalbuminemia:

• In the SAFE study, the saline-to-albumin ratio was significantly higher in patients with baseline albumin ≤25 g/L compared to >25 g/L, suggesting greater volume effectiveness when albumin is low 6
• In hemodialysis patients with albumin <30 g/L, 25% albumin improved hypotension, lowest intradialytic systolic BP, and ultrafiltration rate compared to saline 1
• Volume effectiveness of 20% albumin appears greater when serum albumin levels are low 6
• However, albumin retention is reduced in septic patients (68.5% at 4 hours) compared to healthy controls (79% at 4 hours, p<0.001) 4

Practical Considerations

Fluid Management Strategy:

• Balanced crystalloids (Ringer's lactate) remain first-line for fluid resuscitation in sepsis/septic shock 1, 3
• Consider 20% albumin when large volumes of crystalloids are needed and serum albumin is low 6, 7
• Hyperoncotic albumin facilitates restrictive fluid therapy and may aid deresuscitation when combined with diuretics 7

Cost-Benefit Analysis:

• 20% albumin costs approximately $130/25g USD, significantly more expensive than crystalloids 2
• For hemodialysis patients, thrice-weekly albumin would cost ~$20,000/patient/year 1
• Cost must be weighed against potential benefits in specific clinical scenarios 2

Adverse Effects to Monitor:

• Fluid overload 2
• Hypotension 2
• Hemodilution requiring RBC transfusion 2
• Anaphylaxis 2
• Peripheral gangrene from dilution of natural anticoagulants 2
• One observational study suggested increased renal failure risk with 20% albumin in shock, though RCTs and meta-analyses have not confirmed this 1

Common Pitfalls to Avoid

• Do not use 20% albumin routinely for volume resuscitation without specific indications 1, 2
• Do not assume benefits in traumatic brain injury—albumin is contraindicated 5
• Do not use albumin solely to correct low serum albumin levels 2
• Do not extrapolate cirrhosis evidence to general ICU populations 1, 2
• Recognize that while physiological benefits exist in septic shock (lower fluid balance, improved hemodynamics), mortality benefit remains unproven in most studies 1