What is the proper procedure for administering an albumin infusion?

How to Administer Albumin Infusion

Albumin should be administered intravenously using 20% or 25% concentration for most cirrhosis-related indications, with specific dosing protocols that vary by clinical scenario—always infuse slowly to prevent circulatory overload, particularly in patients with compromised cardiac function. 1, 2

General Administration Principles

Preparation and Route

• Always administer albumin by intravenous infusion only 3
• Use 20% or 25% albumin solution for most indications to minimize fluid volume 2, 4
• May be given undiluted or diluted in 0.9% sodium chloride or 5% dextrose in water 3
• For sodium restriction, use only undiluted albumin or dilute in sodium-free 5% dextrose 3
• Inspect solution visually for particulate matter and discoloration before administration 3
• Use only 16-gauge needles or dispensing pins for vials 20 mL or larger 3
• Swab stopper with antiseptic immediately before entering vial 3

Infusion Rate Considerations

• In hypoproteinemic patients with normal blood volumes, do not exceed 2 mL per minute infusion rate to prevent circulatory overload and pulmonary edema 3
• Slower infusion rates are recommended to prevent cardiac overload, especially in patients with preexisting cirrhomyopathy 1
• Monitor patients carefully throughout infusion to guard against circulatory overload 3

Specific Dosing Protocols by Indication

Large-Volume Paracentesis (>5 Liters)

• Administer 8g albumin per liter of ascites removed 1, 2, 5
• Use 20% or 25% albumin solution 5, 4
• Infuse albumin after paracentesis completion to prevent post-paracentesis circulatory dysfunction 2
• For patients with acute-on-chronic liver failure (ACLF), use 6-8g/L regardless of volume removed 1
• Small-volume paracentesis (<5L) generally does not require albumin replacement 5

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5g/kg within 6 hours of diagnosis (Day 1) 1, 2
• Follow with 1g/kg on Day 3 1, 2
• Base dosing on estimated dry weight 2
• Use 25% albumin to minimize fluid volume in cirrhotic patients 4
• Patients with serum bilirubin >4 mg/dL or baseline AKI (creatinine >1.0 mg/dL and BUN >30 mg/dL) benefit most 1
• Important caveat: Standard dose albumin (1.5g/kg and 1g/kg) infused over 6 hours causes symptomatic circulatory overload in most patients; consider slower infusion over longer periods 6

Hypovolemic Shock

• Adapt volume and infusion speed to individual patient response 3
• Supplement with whole blood transfusion to treat relative anemia from hemodilution 3
• Monitor for bleeding from previously undetected vessels as blood pressure rises 3

Burns (Beyond 24 Hours)

• Target plasma albumin concentration of 2.5 ± 0.5 g/100 mL 3
• Target plasma oncotic pressure of 20 mmHg (equivalent to total protein 5.2 g/100 mL) 3
• Use 25% albumin (Plasbumin-25) for optimal colloid osmotic pressure effect 3
• Duration determined by protein loss from burned areas and urine 3
• Initiate oral or parenteral amino acid feeding; do not use albumin as nutritional source 3

Hypoproteinemia

• Usual adult dose: 50-75g daily 3
• Usual pediatric dose: 25g daily 3
• Patients with severe hypoproteinemia and ongoing albumin loss may require larger quantities 3
• Do not exceed 2 mL per minute infusion rate in patients with normal blood volumes 3

Critical Monitoring and Safety Considerations

Fluid Balance Management

• In dehydrated patients, albumin must be given with or followed by additional fluids because 25% albumin is hyperoncotic 3
• 25% albumin causes plasma volume expansion approximately twice the infused volume 3, 7
• Monitor closely for signs of circulatory overload, particularly pulmonary edema 1, 3
• Hemodilution persists for many hours when blood volume is reduced, but shorter duration with normal blood volume 3

Adverse Events to Monitor

• Fluid overload and pulmonary edema are the primary concerns 1
• Less common: hypotension/tachycardia, rigors, pyrexia, nausea/vomiting, rash/pruritus 1
• Adverse events are generally dose-dependent but can occur at lower doses 1
• Watch for bleeding from previously undetected vessels as blood pressure rises rapidly 3

Drug Compatibility

• Compatible with whole blood, packed red cells, standard carbohydrate and electrolyte solutions 3
• Do not mix with protein hydrolysates, amino acid solutions, or alcohol-containing solutions 3

Common Pitfalls to Avoid

• Never use albumin to treat hypoalbuminemia alone—serum albumin concentration does not reflect albumin function in liver disease 2, 8
• Do not use albumin for routine volume replacement in critically ill patients without specific indications 1, 2
• Avoid rapid infusion rates (>2 mL/min) in hypoproteinemic patients with normal blood volumes 3
• Do not use albumin for infections other than SBP unless associated with AKI—studies show no benefit and increased pulmonary edema risk 1
• Recognize that 5% albumin may cause one-third of volume to leak quickly from plasma due to lower oncotic pressure than patient's own plasma 7