What is the recommended infusion rate and duration for administering 40g of albumin to a patient with spontaneous bacterial peritonitis (SBP) and significant ascitic fluid drainage, likely due to cirrhosis?

Albumin Administration Protocol for Spontaneous Bacterial Peritonitis

Direct Answer

For a patient with SBP and significant ascitic fluid drainage, administer 1.5 g/kg albumin within the first 6 hours of diagnosis, followed by 1 g/kg on day 3—this is a TWO-DOSE protocol only, with no additional albumin needed after day 3 unless there are other specific indications. 1

Dosing Algorithm for 40g Albumin Example

If your patient requires approximately 40g of albumin (suggesting a body weight around 27-40 kg for the first dose):

Day 1 Dose (1.5 g/kg):

• Infusion rate: The guidelines specify administration within the first 6 hours of SBP diagnosis 1
• For 40g albumin: Infuse over 6 hours maximum
• Per hour rate: Approximately 6.7g/hour (or 33 mL/hour if using 20% albumin solution) 1

Day 3 Dose (1 g/kg):

• Amount: Approximately 27g for the same patient
• Infusion duration: Can be given over 6 hours 1
• Per hour rate: Approximately 4.5g/hour

Critical Timing Point:

The first dose MUST be given within 6 hours of SBP diagnosis—this timing is crucial for preventing hepatorenal syndrome and reducing mortality. 1, 2

Duration of Therapy: Only 2 Doses Total

You give albumin on TWO days only: Day 1 (at diagnosis) and Day 3—then STOP. 1 There is no continuation beyond day 3 for SBP treatment. This is not a daily or ongoing therapy.

The protocol is specifically:

• Day 1: 1.5 g/kg within first 6 hours of diagnosis 1
• Day 3: 1 g/kg 1
• Days 2,4,5+: No albumin (unless other indications exist)

Evidence for This Specific Regimen

This two-dose protocol reduced mortality from 29% to 10% and decreased hepatorenal syndrome from 30% to 10% in the landmark randomized controlled trial. 1 The European Association for the Study of the Liver gives this a Level A1 recommendation—the highest grade of evidence. 1

When to Use This Protocol

Albumin is particularly beneficial in high-risk SBP patients with:

• Serum bilirubin ≥4 mg/dL (68 μmol/L) 1
• Serum creatinine ≥1 mg/dL (88 μmol/L) 1

For patients with bilirubin <4 mg/dL AND creatinine <1 mg/dL, the benefit is less clear (hepatorenal syndrome risk was only 7% without albumin vs 0% with albumin), but current guidelines still recommend albumin for all SBP patients. 1

Important Safety Considerations

Infusion Rate Warning:

A critical 2023 study found that the standard dose albumin (1.5 g/kg) infused over 6 hours caused symptomatic circulatory overload in 100% of patients, requiring premature cessation. 3 This suggests:

• Consider slower infusion over 8-12 hours for the first dose to prevent pulmonary edema, especially in patients with baseline cardiac dysfunction 1, 3
• Monitor closely for respiratory distress during infusion 3
• Stop infusion immediately if pulmonary edema develops 3

Pulmonary Edema Risk:

Albumin administration carries an 8.3% risk of pulmonary edema in critically ill cirrhotic patients, which can be fatal. 4 This risk is higher with:

• Higher MELD scores 4
• Pre-existing cardiac dysfunction 1
• Rapid infusion rates 1, 3

What NOT to Do

Do NOT use albumin for infections other than SBP—a 2015 randomized trial showed no survival benefit and increased pulmonary edema risk (8.3%) in non-SBP infections. 4

Do NOT continue albumin beyond day 3 for SBP treatment—there is no evidence supporting extended therapy, and it increases cost and complication risk without benefit. 1

Do NOT use albumin for routine ascites management without large-volume paracentesis or SBP—it provides no mortality benefit in uncomplicated ascites. 5, 2

Alternative Dosing Consideration

One 2019 study used a lower dose protocol (30g on day 1 and day 3, regardless of weight) with acceptable outcomes: 18.3% hepatorenal syndrome rate and 4% immediate mortality. 6 However, this contradicts the weight-based dosing in major guidelines and should only be considered if standard dosing causes intolerable side effects. 1

Summary of Your Specific Question

For your 40g albumin dose:

• Hour 1-6: Infuse the 40g (if this represents your day 1 dose of 1.5 g/kg)
• Day 3: Give second dose of 1 g/kg (approximately 27g for same patient)
• After day 3: STOP albumin—no further doses needed for SBP treatment 1