What are the considerations for albumin administration in patients?

Albumin Administration: Key Considerations

Albumin should NOT be used routinely in most critically ill patients for volume replacement or to correct hypoalbuminemia, but IS indicated for specific cirrhosis complications including large-volume paracentesis (>5L), spontaneous bacterial peritonitis, and hepatorenal syndrome. 1

When Albumin IS Indicated

Cirrhosis-Related Indications (Strong Evidence)

Large-Volume Paracentesis (>5L)

• Administer 8 g of albumin per liter of ascites removed after the procedure is completed 2
• This prevents paracentesis-induced circulatory dysfunction 1
• Doses exceeding 87.5 g (>4×100 mL of 20% albumin) may worsen outcomes due to fluid overload 2

Spontaneous Bacterial Peritonitis

• Give 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 2
• This reduces kidney impairment and mortality 2

Hepatorenal Syndrome

• Albumin is uniformly administered in treatment protocols, though specific dosing varies 1

Other FDA-Approved Indications

Emergency hypovolemic shock (when hyperoncotic 25% albumin is used, it expands plasma volume 3-4 times the infused volume) 3

Cardiopulmonary bypass (to achieve hematocrit of 20% and plasma albumin of 2.5 g/dL) 3

Neonatal hemolytic disease (1 g/kg given 1 hour prior to exchange transfusion to bind bilirubin) 3

When Albumin Is NOT Recommended

Critical Care Settings (Moderate to High Quality Evidence)

Do NOT use albumin for:

• First-line volume replacement in critically ill adults (excluding burns/ARDS) 1
• Correcting hypoalbuminemia alone 1, 4
• Thermal injuries or ARDS for volume replacement 1
• Mobilizing extravascular fluid with diuretics 1

Pediatric and Neonatal Populations

Do NOT use albumin for:

• Preterm neonates with respiratory distress and low albumin 1
• Preterm neonates requiring volume replacement 1
• Pediatric cardiovascular surgery (priming or volume replacement) 1

Other Settings

Do NOT use albumin for:

• Intradialytic hypotension or improving ultrafiltration during dialysis 1
• Cardiovascular surgery in adults 1, 2
• Chronic nephrosis (albumin is promptly excreted with no benefit) 3
• Protein nutrition in malabsorption, cirrhosis, or malnutrition 3

Critical Safety Considerations

Monitoring Requirements

Fluid overload is the primary risk, particularly in cirrhotic patients receiving higher doses or rapid administration 2

Monitor carefully for:

• Circulatory overload (mandatory monitoring per FDA labeling) 3
• Rising serum creatinine during infusion 2
• Rapid blood pressure increases that may unmask previously controlled bleeding 3

Dehydration Precautions

If using 25% hyperoncotic albumin in dehydrated patients:

• Must give with or followed by crystalloid fluids 3
• Alternatively, use 5% iso-oncotic albumin instead 3

Additional Adverse Effects

Documented complications include:

• Hypotension 1, 4
• Hemodilution requiring RBC transfusion 1, 4
• Anaphylaxis 1, 4
• Peripheral gangrene from dilution of natural anticoagulants 1, 4

Dosing Considerations

Concentration Selection

25% albumin (hyperoncotic):

• Expands plasma volume 3-4 times the infused volume 3
• Used for oncotic deficits, not simple volume replacement 3
• Requires adequate hydration or concurrent crystalloids 3

5% albumin (iso-oncotic):

• Preferred for usual volume deficits 3
• Better choice in dehydrated patients 3

Administration Timing

For spontaneous bacterial peritonitis: Within 6 hours of diagnosis 2

For large-volume paracentesis: After procedure completion 2

For cardiac surgery (in research protocols): Administered on ICU arrival and continued for 15 hours 2

Common Pitfalls to Avoid

Do not use albumin to "correct" low albumin levels - treat the underlying cause instead (malnutrition, inflammation, capillary leak) 4

Do not exceed 2 g/kg total dose in the absence of active bleeding 3

Do not mix with protein hydrolysates, amino acid solutions, or alcohol-containing solutions 3

In hemorrhage, supplement albumin with whole blood transfusion to treat relative anemia from hemodilution 3

Cost and Resource Considerations

Albumin costs approximately $130 per 25g (US warehouse acquisition cost), making it substantially more expensive than crystalloids 1

This high cost, combined with limited evidence of benefit in most settings, supports restricting use to well-defined indications 1, 5