What is the recommended dose of 5% human albumin (Human Albumin) for a patient with severe burns?

Albumin Dosing for Severe Burns

For patients with severe burns (>30% TBSA), administer 5% human albumin at a dose of 1-2 g/kg/day starting after the first 6-12 hours post-burn, targeting serum albumin levels >30 g/L to reduce crystalloid requirements, prevent fluid overload complications, and decrease mortality. 1

Timing and Initiation Criteria

Start albumin administration between 6-12 hours post-burn in patients meeting the following criteria: 1

• Total body surface area (TBSA) >30% is the primary threshold for albumin use 1
• Crystalloid requirements trending toward >6 mL/kg/%TBSA at 12 hours post-burn, indicating difficult resuscitation 2
• Patients with TBSA 20-30% may benefit if they demonstrate excessive fluid requirements or signs of fluid creep 1

The guideline explicitly states albumin should be initiated after the first 6 hours of management, as earlier administration does not prevent burn wound edema formation but does reduce non-burn tissue edema. 1

Specific Dosing Protocol

Adults

• Dose: 1-2 g/kg/day of 5% albumin solution 1, 3
• Target: Maintain serum albumin levels >30 g/L 1, 3
• This translates to approximately 50-75 g daily for most adults 4
• Rate of administration should not exceed 2 mL/minute in hypoproteinemic patients to avoid circulatory overload and pulmonary edema 4

Pediatric Patients

• For children with TBSA >15%: Administer 5% albumin starting at 8-12 hours post-burn 1
• Typical pediatric dose: 25 g daily, adjusted based on weight and response 4
• Earlier administration (8-12 hours vs 12+ hours) in children decreases crystalloid requirements, fluid creep incidence, and hospital length of stay 1

Clinical Benefits and Evidence Quality

The evidence supporting albumin use is compelling when high-bias studies are excluded:

• Mortality reduction: OR 0.34 (95% CI 0.19-0.58, P<0.001) when albumin is given within the first 24 hours 1, 5
• Abdominal compartment syndrome reduction: 15.4% to 2.8% (P<0.05) with OR 0.19 1
• Reduced crystalloid volumes and decreased organ failure incidence 1
• Improved fluid balance with lower input-to-output ratios 6

Recent prospective data from the ABRUPT trial (2023) confirms that albumin is preferentially used in older patients with larger burns, higher SOFA scores, and inhalation injury, and is initiated when crystalloid rates exceed expected targets. 6

Practical Implementation Algorithm

Hour 0-6 Post-Burn:

• Resuscitate with balanced crystalloids only (Lactated Ringer's preferred) 7, 5
• Calculate 24-hour needs using Parkland formula: 2-4 mL/kg/%TBSA 7, 5
• Monitor urine output (target 0.5-1 mL/kg/hour) 1, 7

Hour 6-12 Post-Burn:

• If crystalloid requirements trending >6 mL/kg/%TBSA: Initiate 5% albumin 2
• If TBSA >30%: Initiate albumin regardless of crystalloid rate 1
• Begin albumin at 1-2 g/kg/day divided doses 1, 3

Hour 12-24 Post-Burn:

• Continue albumin if already started 1
• For intermediate fluid requirements not meeting early criteria, consider starting albumin at this point 6
• Check serum albumin level and adjust dosing to maintain >30 g/L 1

Beyond 24 Hours:

• Continue albumin supplementation to maintain serum levels >30 g/L 1
• Duration determined by ongoing protein losses from burn wounds and urine 4
• Maximum daily dose should not exceed 100 g 3

Critical Caveats and Pitfalls

Do NOT use albumin for:

• Routine correction of hypoalbuminemia beyond acute resuscitation phase - multiple studies show no mortality benefit and significant cost without clinical improvement 8, 9, 10
• Burns <20% TBSA unless specific complications arise 1
• First 6 hours post-burn - crystalloids alone are appropriate initially 1

Contraindications:

• Never use hydroxyethyl starches (HES) in burn patients - explicitly contraindicated by European Medicines Agency and ANSM 1, 3

Monitoring requirements:

• Watch for pulmonary edema, especially if infusion rate exceeds 2 mL/minute 4
• Monitor intra-abdominal pressure as albumin significantly reduces but does not eliminate compartment syndrome risk 1, 5
• Track serum albumin levels to guide ongoing dosing 1

Conflicting Evidence and Nuances

While the 2020 Anaesthesia guidelines strongly support albumin use, some retrospective studies show conflicting results. A 2013 study found no benefit to routine albumin supplementation for maintaining albumin >20 g/L, with significantly higher costs. 9 However, this study used a lower target (20 g/L vs 30 g/L) and did not focus on the acute resuscitation phase. 9

The key distinction is timing and indication: albumin during acute resuscitation (first 24 hours) for severe burns shows mortality benefit, while chronic supplementation solely to correct hypoalbuminemia after resuscitation does not. 1, 8, 9, 10 The 2012 study by Navickis specifically showed that early albumin use (within 24 hours) in difficult-to-resuscitate patients decreased ventilator days and mortality. 2

The evidence strongly supports albumin use during acute resuscitation for severe burns, but not for chronic supplementation to correct laboratory values alone. 1, 10, 2