What is the role of albumin in fluid resuscitation during the first 24 hours in patients with severe burns?

Role of Albumin in First 24 Hours of Burn Resuscitation

Albumin should be initiated at 8-12 hours post-burn in severe burn patients (≥20% TBSA) when crystalloid requirements exceed expected targets, using 5% albumin to maintain serum levels >30 g/L at doses of 1-2 g/kg/day. 1

Initial Resuscitation Strategy (0-8 Hours)

• Start with crystalloid-only resuscitation using Ringer's Lactate or Hartmann's solution, avoiding normal saline due to hyperchloremic acidosis risk 2, 1
• Administer 20 mL/kg bolus within the first hour, then calculate 24-hour requirements using the Parkland formula (3-4 mL/kg/%TBSA) 2, 3
• Give half of the calculated 24-hour fluid in the first 8 hours, targeting urine output of 0.5-1 mL/kg/hour 2, 1

Albumin Initiation Criteria (8-24 Hours)

The decision to add albumin depends on crystalloid response patterns:

• Early albumin (≤12 hours): Initiate when patients have the highest initial fluid requirements and fail to respond to crystalloid alone 4
• Delayed albumin (>12 hours): Consider when patients have intermediate fluid requirements but crystalloid rates remain above Parkland targets 4
• No albumin needed: Patients who respond adequately to crystalloid alone should not receive albumin 4

Albumin Administration Protocol

• Use 5% albumin solution starting at 8-12 hours post-burn 1
• Target serum albumin levels >30 g/L with typical doses of 1-2 g/kg/day 1
• This approach reduces total crystalloid volumes and prevents "fluid creep" complications 1, 5

Evidence Supporting This Approach

The most recent multicenter prospective trial (ABRUPT, 2023) involving 379 patients demonstrated that albumin supplementation is strategically used when crystalloid rates exceed targets, resulting in improved fluid balance (lower in-to-out ratios) despite patients receiving albumin having larger burns and more severe presentations 4. A 2021 study confirmed that rescue albumin decreases total fluid administered per %TBSA and restores end-organ perfusion as evidenced by improved urine output 5.

Critical Contraindications

• Never use hydroxyethyl starches (HES) in burn patients - they are explicitly contraindicated by European regulatory agencies 1
• Avoid gelatins and synthetic starches due to negative effects on coagulation 1

Common Pitfalls to Avoid

• Do not delay albumin when crystalloid requirements are clearly excessive (>6 mL/kg/%TBSA in first 24 hours), as this leads to fluid creep complications including compartment syndrome, pulmonary edema, and intestinal edema 2, 1
• Do not use albumin immediately (0-8 hours) in all patients - reserve it for those failing crystalloid resuscitation, as increased capillary permeability during this period limits colloid effectiveness 6
• Avoid over-resuscitation: Studies show 76% of resuscitations exceed upper Parkland limits, averaging 6.3 mL/kg/%TBSA 2

Special Populations

• Pediatric patients: Albumin has been included empirically in pediatric protocols, with early administration (8-12 hours) reducing crystalloid volumes and hospital stay, though evidence remains controversial 1
• Patients with full-thickness burns: May require volumes at the higher end of the range (4 mL/kg/%TBSA) and benefit more from earlier albumin supplementation 2

Monitoring Parameters

• Hourly urine output (target: 0.5-1 mL/kg/hour) 2, 1
• Fluid in-to-out ratio (albumin improves this ratio) 4, 5
• Serum albumin levels (maintain >30 g/L) 1
• Signs of fluid overload (compartment syndrome, pulmonary edema) 2