What is the role of albumin in burns fluid resuscitation?

Albumin in Burns Fluid Resuscitation

Albumin should be administered to severe burn patients with total body surface area (TBSA) >30% after the first 6-8 hours of management, targeting serum albumin levels >30 g/L with doses of 1-2 g/kg/day, as this significantly reduces mortality, decreases crystalloid requirements, and prevents complications related to fluid overload. 1

Initial Resuscitation Strategy

• Start with crystalloid resuscitation only using balanced crystalloid solutions (preferably Ringer's Lactate) at 20 mL/kg within the first hour for adults with TBSA ≥15% and children with TBSA ≥10% 2
• Calculate 24-hour fluid requirements using the Parkland formula (2-4 mL/kg/%TBSA), with half administered in the first 8 hours post-burn 3
• Avoid normal saline (0.9% NaCl) as it increases the risk of hyperchloremic metabolic acidosis and acute kidney injury compared to balanced solutions 2

When to Add Albumin

The timing and indication for albumin depends on burn severity and initial response:

• For TBSA >30%: Initiate 5% albumin between 6-12 hours post-burn 1, 3
• For difficult-to-resuscitate patients: Add albumin when estimated fluid needs at 12 hours suggest total volume will exceed 6 mL/kg/%TBSA at 24 hours 4
• For pediatric burns (TBSA >15%): Early administration at 8-12 hours post-burn reduces crystalloid requirements, fluid creep incidence, and hospital length of stay 1, 5

The most recent prospective multicenter data (ABRUPT trial, 2023) confirms that albumin is typically started when initial crystalloid rates exceed expected targets, with earlier initiation (≤12 hours) in patients with the highest initial fluid requirements 6.

Albumin Dosing and Targets

• Concentration: Use 5% albumin solution 1, 4, 5
• Dose: 1-2 g/kg/day to maintain serum albumin levels >30 g/L 1, 3
• For large-volume paracentesis in burn patients with ascites: 8 g per liter of ascites removed 7

Evidence for Mortality and Morbidity Benefits

The strongest evidence supporting albumin use comes from meta-analysis showing:

• Significant mortality reduction when studies with high bias are excluded (odds ratio = 0.34; 95% CI = 0.19-0.58; P < 0.001) 1
• Dramatic reduction in abdominal compartment syndrome from 15.4% in controls to 2.8% in albumin-treated patients (P < 0.05; OR = 0.19) 1, 3
• Reduced ventilator days and mortality in patients receiving early albumin protocols 4

A 2012 prospective study demonstrated that early albumin use (when fluid needs would exceed 6 mL/kg/%TBSA at 24 hours) was associated with decreased mortality, shorter mechanical ventilation duration, and less vasopressor use 4.

Mechanism of Benefit

Albumin administration provides multiple advantages beyond simple volume expansion:

• Reduces total crystalloid volume requirements, thereby preventing "fluid creep" and its complications 1, 6, 8
• Improves fluid input-to-output ratio, indicating better intravascular volume maintenance 6
• Decreases complications of fluid overload including acute respiratory distress syndrome, congestive acute kidney injury, and abdominal compartment syndrome 1, 2
• May provide anti-inflammatory and antioxidant activity 1

The 2023 ABRUPT trial found that albumin patients received more total fluid (5.2 vs 3.7 mL/kg/%TBSA/24 hours) but had better I/O ratios, suggesting improved intravascular retention 6.

Pediatric Considerations

Children require special attention regarding albumin timing:

• Higher baseline fluid requirements (approximately 6 mL/kg/%TBSA in first 48 hours) due to higher body surface area-to-weight ratio 2, 3
• Early albumin (8-12 hours post-burn) in children with TBSA >15% significantly reduces crystalloid administration (2.04 vs 3.05 mL/kg/%TBSA on day 1; p = 0.025) 5
• Fluid creep reduction from 56.5% in controls to 4.3% in early albumin group 5
• Shorter hospital stay (14 vs 18 days; p = 0.004) with early albumin administration 5

Critical Contraindications and Warnings

Hydroxyethyl starches (HES) are absolutely contraindicated in severe burns per the European Medicines Agency (EMA) and French National Agency for Drug Safety (ANSM) 1, 3, 7

Important caveats regarding albumin use:

• Avoid in traumatic brain injury patients, as albumin is associated with increased mortality (RR 1.36; 95% CI 0.99-1.87) in trauma subgroups 1, 7
• Monitor for pulmonary edema, particularly with 20-25% albumin concentrations 7
• Not indicated as first-line therapy in most non-burn resuscitation scenarios 7

Monitoring Parameters

Adjust albumin administration based on:

• Urine output: Target 0.5-1 mL/kg/hour 2, 3
• Serum albumin levels: Maintain >30 g/L 1, 3
• Total fluid requirements: If crystalloid needs exceed 6 mL/kg/%TBSA at 12 hours, initiate albumin 4
• Intra-abdominal pressure: Monitor for compartment syndrome, which albumin significantly reduces 1, 3
• Arterial lactate concentration: For adequacy of overall resuscitation 3

Common Pitfalls to Avoid

• Delaying albumin initiation in patients with TBSA >30% beyond 12 hours, missing the window for optimal benefit 1, 5
• Using albumin as first-line therapy instead of crystalloids in the initial 6-8 hours 1, 2
• Failing to recognize "fluid creep" (excessive crystalloid administration) as an indication for albumin rescue therapy 6, 8, 4
• Using HES or other synthetic colloids, which are contraindicated 1, 3
• Administering albumin to trauma patients with brain injury, where it increases mortality 1, 7

Current Practice Patterns

Recent international surveys show that >30% of intensive care physicians frequently use colloids in severe burn management, with human albumin being the most common choice (>60% of respondents) 1. The 2023 ABRUPT trial confirmed that two-thirds of burn centers use albumin supplementation, typically initiated when crystalloid resuscitation proves inadequate 6.