Albumin Administration for Large Volume Paracentesis in Gross Ascites
Administer albumin AFTER completing the paracentesis, not before or during the procedure, at a dose of 8 grams per liter of ascites removed when draining more than 5 liters. 1
Timing of Albumin Administration
- Infuse albumin after the paracentesis is completed, using 20% or 25% albumin solution 1, 2
- Do not give albumin before or during the drainage procedure 2
- Complete the entire paracentesis in a single session, draining to dryness as rapidly as possible over 1-4 hours 2
Albumin Dosing Protocol
For volumes >5 liters (mandatory):
- Give 8 grams of albumin per liter of ascites removed 1
- Example: If you drain 10 liters, administer 80 grams of albumin (320 mL of 25% albumin or 400 mL of 20% albumin) 3
- This is a Level A1 recommendation from multiple international guidelines 1
For volumes <5 liters:
- Albumin is generally not required for smaller volumes 3
- However, consider albumin replacement at 8 g/L even for volumes <5 liters in high-risk patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 2, 3
Clinical Rationale
Albumin prevents post-paracentesis circulatory dysfunction (PICD), which occurs in up to 80% of patients without volume expansion but only 18.5% with albumin. 2 This complication leads to:
- Renal impairment and potential hepatorenal syndrome 3, 4
- Dilutional hyponatremia 3
- Activation of the renin-angiotensin-aldosterone system 5
- Increased mortality and shorter time to readmission 5
The evidence strongly demonstrates that albumin is superior to alternative plasma expanders (dextran-70, polygeline) in preventing PICD, with rates of 18.5% versus 34.4-37.8% respectively 2, 5
Procedure Details
- Drain the ascites completely in one session without arbitrary volume limits 2
- Typical drainage rate is 2-9 liters per hour 2
- Use ultrasound guidance when available to reduce adverse events 2
- Do not artificially slow the drainage rate - historical concerns about rapid removal causing circulatory collapse have been disproven 2
Important Caveats
No need for pre-procedure blood product correction:
- Do not routinely correct INR or platelet count before paracentesis 2
- Studies show safe paracentesis even with INR up to 8.7 or platelets as low as 19×10³/μL 2
- Hemorrhagic complications are infrequent even with severe coagulopathy 1
Post-procedure management:
- After albumin infusion, restart diuretics at the minimum dose necessary to prevent re-accumulation of ascites 1
- The drain should not be left in overnight 2
Cost considerations:
While some studies suggest lower albumin doses (4 g/L) may be effective 6, 7, the strongest guideline recommendations support 8 g/L for volumes >5 liters to ensure optimal prevention of complications 1. The reduction in liver-related complications, readmissions, and mortality justifies the higher dose 1, 5