Albumin Administration in Hypoalbuminemic, Edematous Patients with Sepsis
Direct Recommendation
In a patient with hypoalbuminemia (albumin 20.21 g/L), edema, and sepsis, administer 20% albumin at 20 grams every 8 hours for 3 days as an adjuvant to crystalloid resuscitation, targeting a serum albumin level ≥30 g/L, while closely monitoring for circulatory overload. 1
Clinical Context and Rationale
When to Use Albumin in Sepsis
Albumin should be considered as second-line therapy only after adequate crystalloid resuscitation (minimum 30 mL/kg) when shock persists or worsens despite initial fluid therapy. 1, 2
The Surviving Sepsis Campaign recommends albumin in addition to crystalloids specifically when patients require large volumes of crystalloids without adequate hemodynamic improvement. 3, 1
In refractory septic shock with hypoalbuminemia, 20% albumin shows greater benefits than 4-5% albumin, including improved cardiovascular function, shorter vasopressor duration (3 vs 4 days), and lower volume requirements. 1, 2
Specific Dosing Protocol for Your Patient
For septic shock with hypoalbuminemia:
- Administer 20% albumin solution at 20 grams every 8 hours for 3 days as the evidence-based protocol. 1
- Target serum albumin concentration of ≥30 g/L (3.0 g/dL). 3, 1
- The hyperoncotic 20% solution will expand plasma volume by 3-4 times the infused volume by withdrawing fluid from interstitial spaces. 4
Administration technique:
- May be given undiluted or diluted in 0.9% sodium chloride or 5% dextrose in water. 4
- If sodium restriction is required, dilute only in sodium-free solutions like 5% dextrose. 4
- Use only 16-gauge needles or dispensing pins for vial access. 4
Critical Monitoring Requirements
Preventing Circulatory Overload in Edematous Patients
This is the most important safety consideration in your edematous patient:
Infusion rate should not exceed 2 mL per minute in hypoalbuminemic patients with normal or expanded blood volumes to prevent circulatory embarrassment and pulmonary edema. 4
Monitor closely for signs of circulatory overload, especially given the patient's pre-existing edema and the hyperoncotic nature of 20% albumin. 1, 4
Use transthoracic echocardiography to evaluate volume status and cardiac function during resuscitation. 1
Hemodynamic Targets
- Maintain mean arterial pressure (MAP) ≥65 mmHg as the initial vasopressor goal. 1
- Monitor for normalization of lactate and urine output ≥0.5 mL/kg/h as indicators of shock reversal. 1
- Assess cardiovascular SOFA scores, which should improve with 20% albumin therapy. 2
Managing the Edema Component
Albumin Plus Diuretics Strategy
For the edematous component in your hypoalbuminemic septic patient:
Consider combining 25% albumin (100 mL) with furosemide twice daily to facilitate diuresis while maintaining oncotic pressure. 5, 6
Administer diuretics within 2 hours following albumin infusion for optimal effect. 6
While urine output may be higher at 6 hours with albumin-furosemide combination, evidence shows no difference at 24 hours compared to furosemide alone in critically ill patients. 3
Important caveat: The primary goal in acute sepsis is hemodynamic stabilization, not immediate diuresis. Aggressive diuresis should be deferred until shock is reversed and the patient is hemodynamically stable. 1
Evidence Quality and Limitations
What the Evidence Shows
The largest trial (ALBIOS) with 1,818 septic patients found no mortality benefit at 28 days with 20% albumin (RR 1.00; 95% CI 0.87-1.14), but did show improved cardiovascular function and reduced vasopressor requirements. 3, 2
Meta-analysis of 17 randomized trials showed reduced mortality with albumin versus crystalloids in severe sepsis/septic shock (OR 0.78; 95% CI 0.62-0.99). 1
Albumin does not reduce the need for kidney replacement therapy or improve mortality in most critically ill populations. 3
Why Use It Despite Mixed Evidence?
The recommendation is based on improved hemodynamic parameters, reduced vasopressor duration, and better fluid balance rather than mortality benefit alone. 1, 2
In hypoalbuminemic patients specifically, albumin's volume effectiveness appears greater when serum albumin levels are low, making it more rational in your patient with albumin 20.21 g/L. 7
Albumin has pleiotropic effects including antioxidant properties, positive effects on vessel wall integrity, and potential renal protective effects that may be clinically relevant in sepsis. 8
Common Pitfalls to Avoid
Do not use albumin as first-line fluid resuscitation: Crystalloids remain the first-line treatment, with albumin reserved for refractory shock or when large crystalloid volumes (>30 mL/kg) have been administered without adequate response. 3, 1, 2
Do not use albumin for nutritional purposes or to simply correct hypoalbuminemia: The hypoalbuminemia in sepsis reflects capillary leak and inflammation, not nutritional deficiency. 5, 9
Avoid rapid infusion in edematous patients: The 2 mL/minute maximum rate is critical to prevent pulmonary edema in patients with pre-existing fluid overload. 4
Do not continue albumin indefinitely: The evidence supports a 3-day course; prolonged administration should not be considered a source of nutrition and requires initiation of appropriate nutritional support. 1, 4
Monitor for cardiac contraindications: Excessive albumin can cause pulmonary edema and respiratory failure, particularly in patients with underlying cardiac dysfunction. 1