What is the recommended dosage and administration rate of albumin 20% for a patient with hypoalbuminemia, considering their volume status, cardiac function, and renal function?

How to Administer Albumin 20%

Albumin 20% should be infused at a maximum rate of 2 mL/min (120 mL/hour) in hypoalbuminemic patients to prevent circulatory overload and pulmonary edema, though faster rates may be tolerated in hypovolemic patients. 1

Infusion Rate Guidelines

Standard Rate for Most Indications

• The FDA-approved maximum infusion rate is 2 mL/min (120 mL/hour) for patients with hypoproteinemia and approximately normal blood volumes 1
• This slower rate prevents circulatory embarrassment and pulmonary edema in patients who are not volume-depleted 1
• Research demonstrates that fast infusion (30 minutes) versus slow infusion (120 minutes) produces similar overall volume expansion, with no safety disadvantages in healthy volunteers 2

Volume Status Determines Safe Infusion Speed

• Hypovolemic patients (shock, post-paracentesis) can tolerate faster infusion rates because they have depleted intravascular volume 1
• Euvolemic or hypervolemic patients require the slower 2 mL/min rate to avoid fluid overload 1
• In critically ill cirrhotic patients with sepsis, 20% albumin given at 0.5-1.0 g/kg over 3 hours achieved faster hemodynamic improvement but caused pulmonary complications in 22% requiring discontinuation 3

Dosing by Clinical Indication

Cirrhosis-Related Indications

Large-Volume Paracentesis (>5L):

• Administer 8 g of albumin per liter of ascites removed 4, 5, 6
• Give after paracentesis completion 5, 6
• For a typical 10L paracentesis: 80g albumin = 400 mL of 20% albumin
• Doses exceeding 87.5g (>437 mL of 20% albumin) may worsen outcomes due to fluid overload 6, 7

Spontaneous Bacterial Peritonitis:

• First dose: 1.5 g/kg within 6 hours of diagnosis 5, 6
• Second dose: 1.0 g/kg on day 3 5, 6
• For a 70 kg patient: First dose = 105g (525 mL of 20%), Second dose = 70g (350 mL of 20%)
• This regimen reduces kidney impairment (10% vs 33%) and mortality (10% vs 29%) 6

Hepatorenal Syndrome:

• 20-40 g/day during vasoconstrictor therapy (typically terlipressin) 7
• Rationale achieved after 1-2 days of treatment 7

Hypovolemic Shock

• Dose and infusion speed adapted to individual patient response 1
• Total dose should not exceed 2 g/kg body weight in absence of active bleeding 1
• 20% albumin expands plasma volume by 1.7 times the infused volume 8

Hypoproteinemia

• Usual adult dose: 50-75g daily (250-375 mL of 20% albumin) 1
• Usual pediatric dose: 25g daily (125 mL of 20% albumin) 1
• Must not exceed 2 mL/min infusion rate 1

Preparation and Administration Technique

Before Infusion

• Swab stopper with antiseptic immediately before entering vial 1
• Use only 16-gauge needles or dispensing pins for 20 mL vials and larger 1
• Penetrate stopper perpendicular to plane within raised ring area 1
• Inspect visually for particulate matter and discoloration 1

Dilution Options

• May be given undiluted or diluted in 0.9% saline or 5% dextrose 1
• If sodium restriction required, use only undiluted or diluted in 5% dextrose 1
• Do not dilute in sterile water (risk of hemolysis)

Critical Safety Monitoring

Mandatory Monitoring During Infusion

• Circulatory overload signs: dyspnea, jugular venous distension, pulmonary crackles 6, 7
• Hemodynamic response in shock patients 1
• Fluid balance (albumin increases urine output to 3× infused volume) 8, 2

High-Risk Situations Requiring Slower Rates

• Cardiac dysfunction or heart failure 1
• Renal impairment with oliguria 6
• Cirrhotic patients (22% discontinuation rate due to pulmonary complications in one trial) 3
• Elderly patients with reduced cardiovascular reserve 1

Common Pitfalls to Avoid

Do NOT Use Albumin 20% For:

• Routine volume replacement in critically ill patients (crystalloids are first-line) 4, 5
• Correcting low serum albumin alone without specific complications 5, 6
• Cardiovascular surgery (largest trial showed increased bleeding and infection) 4, 5
• Chronic hypoalbuminemia from cirrhosis, nephrotic syndrome, or malnutrition without acute complications 6, 1

Avoid These Administration Errors:

• Infusing faster than 2 mL/min in normovolemic patients (causes pulmonary edema) 1
• Giving total doses >87.5g in cirrhotic patients (associated with worse outcomes) 6, 7
• Using albumin as protein nutrition source (not justified for this purpose) 1
• Administering to fluid-overloaded patients without diuretics 1

Practical Example Calculations

For 70 kg patient with SBP:

• Day 1: 1.5 g/kg = 105g = 525 mL of 20% albumin
• At 2 mL/min maximum rate = 262 minutes (4.4 hours) minimum infusion time
• Day 3: 1.0 g/kg = 70g = 350 mL of 20% albumin
• At 2 mL/min = 175 minutes (2.9 hours) minimum infusion time

For 10L paracentesis:

• 8 g/L × 10L = 80g = 400 mL of 20% albumin
• At 2 mL/min = 200 minutes (3.3 hours) infusion time
• Give after paracentesis completed 5, 6