What dose of albumin (human albumin) should be administered to a patient with cirrhosis undergoing a 3-liter paracentesis to prevent hypovolemia?

Albumin Dosing for 3-Liter Paracentesis

You do not need to give albumin after a 3-liter paracentesis, as albumin is only recommended for large-volume paracentesis exceeding 5 liters. 1

Volume Threshold for Albumin Administration

• Albumin replacement is indicated only when paracentesis removes more than 5 liters of ascitic fluid 1
• For paracentesis volumes under 5 liters, the risk of developing post-paracentesis circulatory dysfunction (PICD) is low and does not warrant routine albumin administration 1
• The 2021 Gut guidelines explicitly state that albumin should be infused "after paracentesis of >5 L is completed" 1

Standard Dosing When Albumin IS Indicated (>5L removed)

If you were removing more than 5 liters, the standard approach would be:

• Administer 8 grams of albumin per liter of ascites removed 1, 2
• Use 20% or 25% albumin solution to minimize volume load 1, 3
• Infuse the albumin after the paracentesis is completed 1

For example, if 6 liters were removed, you would give 48 grams of albumin (6L × 8g/L), which equals approximately 200 mL of 25% albumin or 240 mL of 20% albumin.

Clinical Rationale for the 5-Liter Threshold

• PICD occurs in up to 70% of patients undergoing large-volume paracentesis without plasma expansion 1
• Albumin reduces the odds of PICD by 61% (OR=0.39,95% CI 0.27-0.55) compared to no treatment or alternative expanders 1
• Albumin also reduces mortality by 36% (OR=0.64,95% CI 0.41-0.98) and hyponatremia by 42% (OR=0.58,95% CI 0.39-0.87) in large-volume paracentesis 1
• However, these benefits are primarily demonstrated in volumes exceeding 5 liters 1

Important Caveats

• Some guidelines suggest considering albumin even for <5L paracentesis in high-risk patients (those with baseline renal dysfunction, prior PICD, or hemodynamic instability), though this is not standard practice 2
• The European Association for the Study of Liver Diseases notes concerns about alternative plasma expanders (dextran, polygeline, hydroxyethyl starch) due to safety issues, making albumin the preferred choice when volume expansion is needed 1
• Two small trials comparing half-dose albumin (4g/L) to standard dose (8g/L) showed no difference in PICD rates, but these were underpowered studies in low-severity cirrhosis patients 1, 4

What to Do for Your 3-Liter Paracentesis

• No albumin administration is required 1
• Monitor the patient for signs of circulatory dysfunction (hypotension, tachycardia, rising creatinine) 1
• Ensure adequate oral fluid intake and continue diuretic therapy as appropriate 1