For a cirrhotic patient after large‑volume paracentesis, how should 20 g of albumin be administered—over 8 hours or more rapidly, and what is the optimal infusion duration?

Albumin Administration After Large-Volume Paracentesis

For a cirrhotic patient after large-volume paracentesis (>5 L), albumin should be infused after the procedure is completed—not during—at a dose of 8 g per liter of ascites removed, administered over 1–2 hours to avoid volume overload. 1, 2

Timing and Rate of Infusion

The albumin infusion should begin immediately after paracentesis completion and be delivered over 1–2 hours. 2 This timeframe balances the need for prompt volume expansion against the risk of circulatory overload, particularly in patients with cirrhotic cardiomyopathy. 2

• The paracentesis itself should be completed rapidly over 1–4 hours, draining ascites to dryness in a single session. 1
• Historical concerns about administering albumin over extended periods (such as 8 hours) are not supported by current evidence and may delay the prevention of post-paracentesis circulatory dysfunction (PICD). 2

Dosing Protocol

The mandatory dose is 8 g of albumin per liter of ascitic fluid removed when >5 L is evacuated. 1, 2

• For a 5 L paracentesis: administer 40 g albumin (200 mL of 20% albumin or 160 mL of 25% albumin). 2
• Use hyperoncotic solutions (20% or 25% albumin); 5% albumin is inadequate for this indication. 2
• Albumin replacement is calculated solely on ascites volume removed, not patient body weight (except in spontaneous bacterial peritonitis). 2

Evidence Supporting Rapid Post-Procedure Administration

Albumin must be given after—not during—the paracentesis to effectively prevent PICD. 1, 2

• Meta-analysis demonstrates that albumin reduces PICD incidence (OR 0.39,95% CI 0.27-0.55) compared to alternative treatments. 3
• Albumin decreases hyponatremia (OR 0.58,95% CI 0.39-0.87) and mortality (OR 0.64,95% CI 0.41-0.98) versus other plasma expanders. 3
• Without albumin, renal impairment occurs in approximately 21% of patients versus 0% with albumin replacement. 2

Common Pitfall: Prolonged Infusion Duration

Administering 20 g of albumin over 8 hours represents both underdosing and excessive infusion time for a typical large-volume paracentesis. 2

• If 5 L was removed, the correct dose is 40 g (not 20 g), constituting a 50% underdose. 2
• The 8-hour infusion timeframe is unnecessarily prolonged and delays the therapeutic benefit of volume expansion. 2
• To correct underdosing, administer the remaining albumin promptly within hours of recognizing the error. 2

Post-Infusion Monitoring (6-Day Window)

Monitor for complications of inadequate albumin replacement: 2

• Renal function: Daily serum creatinine; acute kidney injury is a recognized complication of under-replacement. 2
• Electrolytes: Daily serum sodium; hyponatremia may develop with inadequate dosing. 2
• Plasma renin activity: A >50% rise from baseline indicates early PICD. 2

Special Considerations for Smaller Volumes

For paracentesis <5 L, albumin replacement at 8 g/L can be considered (but is not mandatory) in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury. 1, 2

• Synthetic plasma expanders may be used for volumes <5 L in uncomplicated cases, though albumin remains superior. 1