What is the recommended protocol for administering an albumin (human albumin) and furosemide (Lasix) infusion?

Albumin-Furosemide Infusion Protocol

Administer albumin and furosemide separately using different infusion sites, completing the albumin infusion first followed by furosemide within 2 hours, with specific dosing based on clinical indication. 1, 2

Clinical Context-Specific Protocols

For Cirrhotic Ascites with Large-Volume Paracentesis (>5L)

• Administer 8 g of albumin (20% or 25% solution) per liter of ascites removed after the paracentesis is completed 3, 1, 2
• Resume oral furosemide 40 mg combined with spironolactone 100 mg as a single morning dose after the procedure 1
• For paracentesis <5L, albumin at the same dose (8 g/L) can be considered in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1

For Spontaneous Bacterial Peritonitis (SBP)

• Administer albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 3, 1
• This protocol is particularly critical in high-risk patients with bilirubin >4 mg/dL or serum creatinine >1 mg/dL 3

For Cirrhotic Ascites Without Paracentesis

• Start with oral furosemide 40 mg combined with spironolactone 100 mg as a single morning dose 1
• Increase doses simultaneously every 3-5 days if weight loss and natriuresis are inadequate, up to maximum furosemide 160 mg/day and spironolactone 400 mg/day 3, 1
• Oral administration is strongly preferred over IV in cirrhotic patients due to good bioavailability and to avoid acute reductions in glomerular filtration rate 1

Administration Technique

Sequential Infusion Protocol

• Use different infusion sites for albumin and furosemide—never mix them in the same infusion 1, 2
• Complete the albumin infusion first 1, 2
• Administer furosemide within 2 hours following albumin infusion 2
• Infuse furosemide over 5-30 minutes to minimize ototoxicity risk 4, 2

Dosing Considerations Based on Patient Characteristics

The evidence suggests combination therapy may be more effective in specific populations, though guidelines do not universally endorse this approach:

• Patients with baseline serum albumin <2.5 g/dL may derive greater benefit from combination therapy 5
• Higher albumin doses (>30 g) appear more effective when combination therapy is used 5
• Patients with baseline creatinine >1.2 mg/dL or eGFR <60 mL/min/1.73m² may show enhanced response 5
• However, in critically ill patients without cirrhosis, albumin plus furosemide does not improve mortality, ventilator-free days, or meaningful clinical outcomes 2

Monitoring Requirements

Essential Parameters During Treatment

• Monitor electrolytes (sodium and potassium) regularly 1, 2
• Assess kidney function through urine output and serum creatinine 1, 2
• Evaluate fluid status through daily weight, blood pressure, and clinical examination 1, 2
• Track hemodynamic parameters closely during treatment 1

Target Weight Loss Goals

• In the presence of peripheral edema, no strict limitation on weight loss per day, but decide carefully based on patient condition 3
• In the absence of peripheral edema, target weight loss of 0.5 kg/day 3

Critical Safety Considerations and Contraindications

When to Discontinue or Reduce Diuretics

• Stop or reduce diuretics if severe hyponatremia (sodium <125 mEq/L or drop >10 mEq/L), acute kidney injury (creatinine increase >0.3 mg/dL within 48 hours or 1.5-fold within 1 week), worsening hepatic encephalopathy, or severe muscle cramps develop 3, 1
• Reduce loop diuretics when hypokalemia (potassium <3 mmol/L) occurs 3
• Reduce aldosterone antagonists when hyperkalemia (potassium >6 mmol/L) develops 3

Absolute Contraindications

• Avoid furosemide in patients with marked hypovolemia, as it could worsen hypovolemia and promote thrombosis 4, 2
• Do not administer in patients with anuria 4
• Avoid in patients with severe hypotension 2

Ototoxicity Prevention

• Do not use high doses of furosemide (>6 mg/kg/day) for periods longer than 1 week due to risk of ototoxicity 1, 4, 2
• Always infuse over 5-30 minutes rather than as rapid bolus 4, 2

Common Pitfalls to Avoid

Administration Errors

• Never mix albumin and furosemide in the same infusion, as this may reduce efficacy 1, 2
• Do not administer furosemide before albumin when using combination therapy 1, 2

Inappropriate Use in Non-Cirrhotic Populations

• Do not use albumin in cirrhotic patients with infections other than SBP, as it does not reduce acute kidney injury or mortality risk and may cause pulmonary edema 1
• In acute heart failure with pulmonary edema, combine furosemide with nitrate therapy, not albumin 2
• In general ICU populations without cirrhosis, albumin plus furosemide does not improve outcomes 2, 6

Refractory Ascites Management

• Refractory ascites is defined as failure to respond to maximum diuretic doses (spironolactone 400 mg/day and furosemide 160 mg/day) for at least 1 week on salt-restricted diet (<5 g/day) 3
• In refractory ascites, consider transjugular intrahepatic portosystemic shunt (TIPSS) rather than escalating diuretic doses beyond recommended maximums 1

Monitoring Frequency

Nearly half of patients require diuretic discontinuation or dose reduction due to adverse events, necessitating close monitoring 1