How to administer and calculate the dose of human albumin drip in patients with severe hypoalbuminemia?

How to Administer and Calculate Human Albumin Drip in Severe Hypoalbuminemia

For patients with severe hypoalbuminemia requiring albumin infusion, the specific indication determines both the concentration (5% vs 20-25%) and dosing regimen, with cirrhosis-related conditions having the most robust evidence-based protocols. 1

Primary Clinical Indications and Dosing Algorithms

Large Volume Paracentesis (Most Common Indication)

• Administer 8 g of albumin per liter of ascites removed when >5 L is drained 1
• Use 20% or 25% albumin solution 1
• Calculation example: For 6 L paracentesis → 48 g albumin needed → 192 mL of 25% albumin (or 240 mL of 20% albumin) 1, 2
• Infuse after paracentesis is completed, not during 1
• For <5 L paracentesis, albumin may be considered in high-risk patients (ACLF, elevated creatinine) 1

Spontaneous Bacterial Peritonitis (SBP)

• Day 1: 1.5 g/kg within 6 hours of diagnosis 1
• Day 3: 1.0 g/kg 1
• Use estimated dry weight for calculation (challenging in cirrhotic patients with ascites) 1
• Maximum daily dose should not exceed 100 g 3
• Critical caveat: Doses >87.5 g (>4 vials of 100 mL 20% albumin) may worsen outcomes due to fluid overload 4

Calculation example for 70 kg patient:

• Day 1: 1.5 g/kg × 70 kg = 105 g → reduce to 100 g maximum = 400 mL of 25% albumin 3, 4
• Day 3: 1.0 g/kg × 70 kg = 70 g = 280 mL of 25% albumin 1

Severe Burns (TBSA >30%)

• Start after first 6-8 hours of crystalloid resuscitation 1, 3
• Use 5% albumin solution 1, 3
• Target dose: 1-2 g/kg/day to maintain serum albumin >30 g/L 1, 3, 2
• In pediatric burns (TBSA >15%), early administration at 8-12 hours post-burn reduces crystalloid needs 1, 3

Concentration Selection

When to Use 5% Albumin

• Burns resuscitation 1, 3
• General volume expansion in critically ill patients 3
• Lower risk of volume overload and pulmonary edema 3

When to Use 20-25% Albumin

• Large volume paracentesis 1
• Spontaneous bacterial peritonitis 1
• Hepatorenal syndrome (20-40 g/day during terlipressin treatment) 4
• Septic shock targeting serum albumin >30 g/L 3

Infusion Rate and Safety

Standard Infusion Rates

• Euvolemic patients: Maximum 2 mL/min (≈120 mL/hour for 25% albumin) 4
• Hypovolemic patients: Can infuse more rapidly, but monitor closely 4
• Burns patients: More liberal rates acceptable after 24 hours to maintain albumin >2.5 g/dL 4

Critical Safety Monitoring

• Pulmonary edema risk: Especially with rapid infusion or cardiac/pulmonary insufficiency 4, 2
• Monitor for: hypotension, tachycardia, rigors, pyrexia, rash, nausea 4
• Assess volume status before administration to avoid complications 2
• Infuse slowly in patients with preexisting cardiomyopathy 1

Calculation Formulas

Converting Between Concentrations

• 100 mL of 25% albumin = 25 g albumin
• 100 mL of 20% albumin = 20 g albumin
• 100 mL of 5% albumin = 5 g albumin 2

Expected Serum Albumin Increase

• One 100 mL vial of 25% albumin increases serum albumin by approximately 0.2-0.3 g/dL 2
• Only 40-60% remains in circulation initially due to vascular leak in critical illness 2

Important Contraindications and Caveats

Absolute Contraindications

• Traumatic brain injury: Associated with increased mortality (avoid completely) 3

Relative Contraindications/Cautions

• Not recommended for routine hypoalbuminemia correction without specific indication 3, 4
• Not first-line for volume expansion (crystalloids preferred in most scenarios) 3
• Avoid in uncomplicated ascites without paracentesis 3

When Albumin is NOT Indicated

• General critically ill patients without specific indications 3, 4
• Routine treatment of low serum albumin levels 3, 4
• First-line septic shock resuscitation (crystalloids preferred) 1, 3
• Hemorrhagic shock (no proven benefit) 3

Clinical Pitfalls to Avoid

1. Fluid overload: The most common serious adverse event, particularly when exceeding recommended doses or infusing too rapidly 4
2. Using albumin as first-line therapy: Crystalloids remain first-line for most resuscitation scenarios 3
3. Ignoring volume status: Always assess intravascular volume before administration 2
4. Incorrect weight calculation: Use dry weight for cirrhotic patients, not actual weight with ascites 1
5. Wrong concentration: Using 25% when 5% is indicated (burns) or vice versa can lead to volume issues 1, 3