Albumin Indication in Surgery
Albumin is NOT recommended for routine use in surgery, including cardiovascular surgery, for volume replacement, cardiopulmonary bypass priming, or correction of low serum albumin levels. 1
Evidence-Based Recommendations Against Albumin Use in Surgery
Cardiovascular Surgery
The International Collaboration for Transfusion Medicine Guidelines (2024) explicitly recommends against albumin use in both adult and pediatric cardiovascular surgery. 1
In adult patients undergoing cardiovascular surgery, albumin is NOT suggested for priming the cardiopulmonary bypass circuit or for volume replacement (Conditional Recommendation, Very Low Certainty of Evidence). 1
In pediatric patients undergoing cardiovascular surgery, albumin is NOT suggested for priming the cardiovascular bypass circuit or for volume replacement (Conditional Recommendation, Very Low Certainty of Evidence). 1
Key Evidence from Cardiac Surgery Studies
A systematic review of 43 randomized trials (N=3,862) comparing albumin with gelatin, starches, or crystalloid solutions found: 1
- No mortality benefit (risk difference 0.00; 95% CI, -0.01 to 0.01; N=2,711) 1
- No difference in kidney failure rates (risk difference 0.01; 95% CI, -0.01 to 0.03; N=1,703) 1
- No difference in blood loss, ICU length of stay, hospital length of stay, blood component use, or cardiac index 1
- The largest single trial (1,386 patients) found INCREASED morbidity with albumin, including higher rates of bleeding, resternotomy, and infection when compared with Ringer's lactate 1
General Surgical Patients
For critically ill adult patients undergoing major surgery, albumin is NOT suggested for first-line volume replacement or to increase serum albumin levels (Conditional Recommendation, Moderate Certainty of Evidence). 1
- Despite the fact that patients can lose over half their circulating albumin during major surgery, treatment with albumin has not been shown to improve patient outcomes 2
- The FDA label acknowledges albumin "may be of value" in hypoproteinemia during major surgery, but this is not supported by high-quality evidence 2
Critical Safety Concerns with Albumin in Surgery
Albumin carries significant risks without proven benefit: 1
- Fluid overload 1
- Hypotension 1
- Hemodilution requiring RBC transfusion 1
- Anaphylaxis 1
- Peripheral gangrene from dilution of natural anticoagulants 1
- Increased bleeding complications (demonstrated in the largest cardiac surgery trial) 1
When Albumin Should NOT Be Used
The following are explicitly NOT warranted indications for albumin: 2
- Routine correction of hypoalbuminemia 1, 3
- Nutritional supplementation 2
- First-line volume replacement in surgery 1
- Cardiopulmonary bypass priming (crystalloids are preferred) 1
Practical Algorithm for Surgical Fluid Management
For volume replacement in surgical patients: 1
- First-line: Use crystalloid solutions (e.g., balanced crystalloids like Ringer's lactate) 1
- If inadequate response to crystalloids: Consider blood products if bleeding, or continue crystalloid resuscitation 1
- Do NOT use albumin to correct low serum albumin levels - postoperative hypoalbuminemia (10-15 g/L decrease) is expected and does not require correction 1
- Only consider albumin in specific non-surgical contexts (see below) 3
Limited Evidence-Based Indications (Non-Surgical)
Albumin has strong evidence ONLY in specific liver disease complications: 3
- Large-volume paracentesis in cirrhosis (>5L): 6-8 g per liter of ascites removed 3
- Spontaneous bacterial peritonitis: 1.5 g/kg on day 1 and 1.0 g/kg on day 3, in addition to antibiotics 3
Common Pitfalls to Avoid
- Do not use serum albumin levels as an indication for albumin administration - low albumin is a marker of illness severity, not a treatment target 1, 3
- Do not assume albumin provides superior volume expansion - the largest trials show no benefit over crystalloids and potential harm 1
- Do not use albumin for "oncotic support" without evidence - this theoretical benefit has not translated to improved outcomes 1
- Avoid doses exceeding 87.5 g due to increased risk of fluid overload and worse outcomes 3
Cost Considerations
Albumin is approximately 30 times more expensive than equivalent crystalloid solutions with no demonstrated benefit in surgical patients, making its routine use economically unjustifiable. 4