When should albumin be administered to an adult ICU patient who remains hypotensive after an initial 30 mL/kg isotonic crystalloid bolus, has serum albumin <2.5 g/dL, or has conditions such as cirrhosis with hepatorenal syndrome, large‑volume paracentesis, spontaneous bacterial peritonitis, severe burns, or septic shock?

When to Use Albumin in the ICU

Albumin should NOT be used routinely for volume resuscitation, correction of hypoalbuminemia, or nutritional support in ICU patients—crystalloids remain first-line for fluid resuscitation in septic shock and most critical illness. 1

Primary Evidence-Based Indications (Strong Support)

Cirrhosis-Related Complications

Large-Volume Paracentesis (>5 L)

• Administer 8 g albumin per liter of ascites removed using 20-25% albumin solution 1
• Prevents paracentesis-induced circulatory dysfunction 1, 2
• Infuse slowly to avoid cardiac overload in patients with underlying cirrhomyopathy 1

Spontaneous Bacterial Peritonitis (SBP)

• Give 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1
• Reduces renal dysfunction by ~72% and mortality by ~47% 1, 3
• Use in conjunction with antibiotics 1

Hepatorenal Syndrome

• Administer albumin with vasopressors (terlipressin) 1, 2
• Dosing typically 1 g/kg on day 1, then 20-40 g/day 2

When NOT to Use Albumin (Strong Evidence Against)

Critical Care Settings Where Albumin Fails to Improve Outcomes

Septic Shock and General ICU Resuscitation

• Use crystalloids (balanced or normal saline) as first-line fluid resuscitation 1, 4
• The ALBIOS trial (1,818 patients) showed no mortality benefit at 28 days (RR 1.00; 95% CI 0.87-1.14) 1
• Moderate-certainty evidence demonstrates albumin does not reduce mortality or need for renal replacement therapy compared to crystalloids 1, 3

Traumatic Brain Injury

• Avoid albumin—associated with 62% increased mortality (RR 1.62; 95% CI 1.12-2.34) 1
• Use isotonic saline instead 4

"Correcting" Low Albumin Levels

• Never give albumin solely to raise serum albumin concentration 1, 3, 5
• Hypoalbuminemia is a marker of disease severity, not a therapeutic target 1, 3, 5
• Infused albumin does not improve outcomes in chronic nephrosis, malnutrition, or protein-losing enteropathies 2

Conditional/Controversial Indications (Weaker Evidence)

Sepsis in Cirrhosis (Emerging Data)

• One RCT (308 patients) showed albumin improved 1-week survival vs. saline in cirrhotic patients with sepsis-induced hypotension (43.5% vs. 38.3%, p=0.03) 1
• However, another trial showed higher pulmonary complications with albumin 1
• Consider 5% albumin for septic shock in cirrhosis after crystalloid failure, but monitor closely for fluid overload 1

Severe Burns (After 24 Hours)

• May use albumin beyond 24 hours post-burn to maintain plasma colloid osmotic pressure 2
• First 24 hours: use crystalloids exclusively 2

ARDS with Hypoproteinemia and Fluid Overload

• Consider albumin with diuretics when clinical signs show hypoproteinemia plus volume overload 2
• Evidence remains very low certainty 1

Critical Clinical Algorithm

Step 1: Does the patient have cirrhosis with an acute complication?

• NO → Do not use albumin; use crystalloids for resuscitation 1, 3, 5
• YES → Proceed to Step 2

Step 2: Which cirrhosis complication?

• Large-volume paracentesis (>5 L) → Give 8 g albumin/L removed 1
• SBP diagnosed → Give 1.5 g/kg within 6 hours, then 1.0 g/kg day 3 1
• Hepatorenal syndrome → Give albumin + terlipressin 1, 2
• Septic shock (non-SBP) → Consider albumin if hypotension persists after crystalloids, but monitor for pulmonary edema 1

Step 3: For all other ICU scenarios

• Hypovolemic shock → Crystalloids first-line 1, 4
• Septic shock (non-cirrhotic) → Crystalloids first-line 1
• Low serum albumin → Do not treat the number 1, 3
• Traumatic brain injury → Absolutely avoid albumin 1

Common Pitfalls to Avoid

Pitfall #1: Treating the Laboratory Value

• Low albumin reflects illness severity, not albumin deficiency 1, 3, 5
• The ATTIRE trial showed targeting albumin ≥3 g/dL increased pulmonary edema without benefit 1

Pitfall #2: Fluid Overload

• 25% albumin expands plasma volume 3-4 times the infused volume 2
• Infuse slowly (<2 mL/min) in hypoproteinemic patients 3
• Monitor for pulmonary edema, especially in cirrhosis with cardiac dysfunction 1

Pitfall #3: Cost Without Benefit

• Albumin costs ~$130 per 25 g vs. pennies for crystalloids 3
• Of 14 guideline recommendations, 12 advise against albumin in common scenarios 1, 3, 5

Dosing Summary by Indication

Indication	Dose	Formulation
Large-volume paracentesis	8 g per liter removed	20-25% albumin [1]
SBP	1.5 g/kg day 1.0 g/kg day 3	20-25% albumin [1]
Hepatorenal syndrome	1 g/kg day 1, then 20-40 g/day	20-25% albumin [2]
Neonatal hemolytic disease	1 g/kg 1 hour pre-exchange	25% albumin [2]

Adverse Effects to Monitor

• Pulmonary edema/fluid overload (most common, especially if infused rapidly) 1, 3
• Hypotension (paradoxical) 3
• Hemodilution requiring transfusion 3
• Anaphylaxis (rare) 3