Albumin Dosing for Hypotensive Blood Pressure Support
For hypotensive patients requiring blood pressure support, albumin is NOT the preferred first-line agent—vasopressors and crystalloids should be used instead, as albumin has not demonstrated mortality benefit in septic shock and carries significant risks of pulmonary complications.
Primary Recommendation Based on Strongest Evidence
In septic shock with hypotension, use crystalloids (isotonic saline or balanced solutions like Plasmalyte) as the initial resuscitation fluid, NOT albumin. 1 The 2012 Surviving Sepsis Campaign guidelines recommend initial resuscitation with crystalloids or albumin at 20 mL/kg boluses over 5-10 minutes, but more recent evidence shows albumin offers no survival advantage and increases complications. 1
Context-Specific Albumin Dosing (When Used)
For Septic Shock in Cirrhosis Patients
- 5% albumin is superior to 20% albumin for sepsis-induced hypotension in cirrhosis, with better safety profile 2, 3
- Dose: 0.5-1.0 g/kg over 3 hours (approximately 35-70g for a 70kg patient) 2
- 5% albumin achieved MAP ≥65 mmHg in 43.5% vs 39% with saline at 7 days, though 20% albumin caused treatment discontinuation in 22% of patients due to pulmonary complications 2, 3
For Intradialytic Hypotension
- Dose: 100 mL of 25% albumin (25g) at dialysis initiation 4
- This reduced hypotension episodes from 15% to 7% and improved ultrafiltration rates 4
- Alternative strategy: Midodrine 5-10 mg orally 30 minutes before dialysis is safer and more cost-effective than albumin 1, 5
Critical Safety Concerns
Pulmonary Complications
- 20% albumin causes circulatory overload requiring treatment discontinuation in 22% of patients with cirrhosis and septic shock 2
- Albumin in cirrhosis with extraperitoneal infections increased pulmonary edema 5-fold (OR 5.17,95% CI 1.62-16.47) 1
- The ALPS trial showed 20% albumin caused more pulmonary complications than Plasmalyte despite faster hemodynamic improvement 2
Paradoxical Hypotension Risk
- Rapid albumin infusion can cause paradoxical hypotension, especially in patients on ACE inhibitors 6
- 11% of cardiac surgery patients experienced hypotension with 4% albumin, with 75% of cases occurring in ACE inhibitor users (p=0.04) 6
- Mechanism involves bradykinin generation through pre-kallikrein activator presence 6
No Mortality Benefit
- 28-day mortality was identical between 20% albumin and Plasmalyte (58% vs 62%, p=0.57) in cirrhotic patients with septic shock 2
- The ALBIOS trial in general septic shock showed no mortality difference with albumin 1
Practical Algorithm for Hypotension Management
Step 1: Initial Assessment
- If septic shock WITHOUT cirrhosis: Use crystalloids 20-30 mL/kg boluses, NOT albumin 1
- If septic shock WITH cirrhosis: Consider 5% albumin 0.5-1.0 g/kg over 3 hours 2, 3
- If intradialytic hypotension: Use midodrine 5-10 mg pre-dialysis as first-line; reserve albumin 25g for refractory cases 1, 5, 4
Step 2: Monitor for Complications
- Watch for hepatomegaly or rales—if present, STOP fluid and start inotropes 1
- Monitor for pulmonary edema, especially with 20% or 25% albumin 1, 2
- Check for paradoxical hypotension if patient takes ACE inhibitors 6
Step 3: Vasopressor Initiation
- Begin vasopressors if MAP remains <65 mmHg after initial fluid resuscitation 1
- Peripheral inotropic support can be started before central access in children 1
Key Pitfalls to Avoid
Do NOT use albumin as first-line for general septic shock—it offers no mortality benefit over crystalloids and costs significantly more 1
Do NOT use 20% albumin in cirrhotic patients with sepsis—5% albumin is safer with fewer pulmonary complications 2, 3
Do NOT infuse albumin rapidly in patients on ACE inhibitors—risk of paradoxical hypotension increases 3-fold 6
Do NOT continue albumin if hepatomegaly or rales develop—switch to inotropes immediately 1
Do NOT use albumin for neuroprotection in acute ischemic stroke—the ALIAS2 trial was stopped early for safety concerns 1