20% Albumin at 10ml/hr is NOT Appropriate for Hypovolemic Shock
Isotonic crystalloids (normal saline or Ringer's lactate) administered as rapid boluses of 10-20 ml/kg are the first-line treatment for hypovolemic shock, not slow-infusion albumin. 1
Why This Infusion Rate is Problematic
The 10ml/hr infusion rate you've specified is fundamentally incompatible with the pathophysiology of hypovolemic shock:
- Hypovolemic shock requires rapid volume expansion with boluses of 500-1000 ml in adults over 30 minutes, or 10-20 ml/kg in children over 5-10 minutes 1, 2
- At 10ml/hr, a 50kg patient would receive only 240ml over 24 hours - this is inadequate for any meaningful resuscitation 3
- The FDA labeling for 25% albumin specifically states that administration speed should be adapted to individual patient response in hypovolemic shock, not fixed at arbitrary slow rates 3
First-Line Treatment: Crystalloids
Grade A recommendation: Isotonic saline is the first-choice fluid for initial resuscitation in hypovolemic shock 1
Initial Resuscitation Protocol:
- Adults: 500-1000 ml crystalloid boluses over 30 minutes, repeated based on clinical response 2
- Children: 10-20 ml/kg boluses over 5-10 minutes, up to 60 ml/kg in the first hour for severe shock 1, 2
- Reassess after each bolus: Check capillary refill (<2 seconds goal), blood pressure, heart rate, mental status, and urine output (>1 ml/kg/hr goal) 2
When 20% Albumin Has a Role (But Not at 10ml/hr)
20% albumin may be considered in specific hypovolemic shock scenarios, but always as rapid infusion, not slow drip:
Appropriate Uses:
- After large crystalloid volumes in septic shock with hypoalbuminemia - the ALBIOS trial showed mortality benefit (OR 0.87) when maintaining elevated albumin levels in septic shock 4
- When 2-4 times the crystalloid volume would be needed - albumin provides more sustained volume expansion than crystalloids 5, 6
- In patients developing fluid overload from crystalloids - 20% albumin may reduce net fluid balance 7
Critical Caveat:
Even when albumin is indicated, it must be given as boluses or rapid infusions titrated to hemodynamic endpoints, not as a slow continuous infusion 3, 5
Where 20% Albumin is NOT Recommended
- Routine volume replacement in critically ill adults - not superior to crystalloids for general resuscitation 4
- Pediatric febrile illness with shock - associated with excess mortality in children 4
- Trauma or burn patients - albumin showed increased mortality (RR 1.36 for trauma) and increased ventilator requirements 1
Cost Considerations
- 20% albumin costs approximately $130 per 25g versus $1.50 per liter of isotonic saline 1, 4
- This 87-fold cost difference mandates restricting albumin to evidence-based indications only 1
Monitoring During Proper Resuscitation
Regardless of fluid type, monitor for:
- Response indicators: Normalized heart rate, blood pressure, capillary refill <2 seconds, warm extremities, adequate urine output 2
- Overload signs: Pulmonary edema, hepatomegaly, elevated jugular venous pressure - if present, slow infusion and consider vasopressor support 2
- Lactate clearance: Serial measurements guide adequacy of resuscitation 2
Common Pitfalls to Avoid
- Fixed slow infusion rates in shock states - this delays definitive resuscitation and worsens outcomes 1, 2
- Using albumin as first-line therapy - crystalloids are equally effective and vastly less expensive for initial resuscitation 1
- Administering albumin to "correct" low serum albumin without shock - serum concentration doesn't reflect albumin function and routine supplementation is not indicated 4
- Excessive crystalloid administration without reassessment - leads to fluid overload and pulmonary edema 2, 5
The rate of 2 ml/min maximum for hypoproteinemic patients specifically applies to those WITHOUT hypovolemia to prevent circulatory overload - this is the opposite clinical scenario from hypovolemic shock 3