Albumin Infusion Rate for ICU Patients
Direct Answer
Albumin should be infused slowly over several hours in ICU patients, with specific rates depending on clinical context: for cirrhosis-related indications, infuse after paracentesis completion or within 6 hours for spontaneous bacterial peritonitis; for general ICU use, limit to ≤2 mL/min (≈120 mL/hour for 25% albumin) in euvolemic patients to prevent fluid overload. 1
Context-Specific Infusion Protocols
Cirrhosis-Related Indications
Post-Paracentesis (>5L removed):
- Administer 8g albumin per liter of ascites removed after the paracentesis procedure is completed 2, 3
- Infuse slowly to prevent cardiac overload, particularly important given preexisting cirrhotic cardiomyopathy 2
- Avoid doses exceeding 87.5g (>4×100 mL of 20% albumin) due to association with worse outcomes from fluid overload 3, 1
Spontaneous Bacterial Peritonitis:
- First dose: 1.5 g/kg within 6 hours of diagnosis 2, 3, 4
- Second dose: 1.0 g/kg on day 3 2, 4
- This protocol reduces renal impairment (10% vs 33%) and mortality (22% vs 41%) compared to antibiotics alone 2
Hepatorenal Syndrome:
- Administer 20-40 g/day during terlipressin treatment 1
- The rationale for albumin is typically achieved after a short course of 1-2 days 1
General ICU Resuscitation
Volume Status-Based Algorithm:
Hypovolemic patients: Can tolerate faster infusion rates for hemodynamic stabilization 1
Euvolemic patients: Limit to ≤2 mL/min (≈120 mL/hour for 25% albumin) 1
Patients with normal/elevated blood volumes: Avoid rapid infusion due to increased pulmonary edema risk 1
Important caveat: The 2022 French guidelines explicitly state albumin is probably not recommended as first-line treatment in sepsis/septic shock compared to crystalloids for reducing mortality or renal replacement therapy requirement 2. However, when large volumes of crystalloids are needed and serum albumin is low, albumin may be considered as adjunctive therapy 4.
Critical Safety Monitoring
Mandatory monitoring during infusion includes: 3, 1
- Circulatory overload (particularly in cirrhotic patients)
- Hypotension
- Hemodilution requiring RBC transfusion
- Anaphylaxis
- Signs of peripheral gangrene from dilution of natural anticoagulants
High-risk scenarios requiring slower infusion:
- Doses exceeding 87.5g total 3, 1
- Patients with elevated or rising serum creatinine 3
- Cirrhotic patients with preexisting cardiomyopathy 2
Evidence-Based Rationale
The volume effectiveness of albumin appears greater when serum albumin levels are low, acting as an effect moderator in resuscitation 5. In the SAFE study comparing 4% albumin to saline, the saline-to-albumin ratio was significantly higher in patients with baseline albumin ≤25 g/L versus >25 g/L 5. This suggests hypoalbuminemia influences the crystalloid-sparing effect of albumin administration.
Key limitation: Despite theoretical benefits, five of six meta-analyses found no mortality benefit with either 4-5% or 20% albumin in sepsis 2. Only one meta-analysis by Xu et al. showed 90-day mortality benefit in septic shock (OR 0.81,95% CI 0.67-0.97) 2, 4. The ALBIOS trial showed mortality benefit only in the septic shock subgroup (OR 0.87,95% CI 0.77-0.99), not in general sepsis 2, 4.
Common Pitfalls to Avoid
- Do not use serum albumin levels alone to guide infusion rate; volume status is the critical determinant 1
- Do not infuse rapidly in euvolemic patients—this increases pulmonary edema risk 1
- Do not exceed 87.5g without careful monitoring for fluid overload 3, 1
- Do not use albumin routinely for correcting hypoalbuminemia without specific indications (cirrhosis complications, large-volume paracentesis >5L, spontaneous bacterial peritonitis) 3, 4
Cost Considerations
Albumin costs approximately $130 per 25g, making it substantially more expensive than crystalloids 3, 4. This high cost, combined with limited mortality benefit in most ICU settings, supports restricting use to well-defined indications where benefit is proven (cirrhosis-related complications) rather than general volume resuscitation 3.