What albumin dose and administration schedule should be used to treat hypotension in a patient after multiple blood transfusions?

Albumin Dosing for Hypotension After Multiple Blood Transfusions

In patients with hypotension following multiple blood transfusions, albumin is NOT recommended as first-line therapy; crystalloid resuscitation (20-30 mL/kg boluses of balanced crystalloids or normal saline) should be used instead, unless the patient has cirrhosis with sepsis-induced hypotension, in which case 5% albumin at 0.5-1.0 g/kg over 3 hours is preferred. 1, 2, 3

Primary Approach: Crystalloids First

• Crystalloids are the fluid of choice for initial resuscitation in hypotensive patients, including those who have received multiple transfusions, based on strong recommendations from the Surviving Sepsis Campaign guidelines 1
• Administer 20-30 mL/kg boluses of balanced crystalloids (lactated Ringer's or Plasma-Lyte) or normal saline over 5-10 minutes, titrated to hemodynamic improvement 1
• Continue fluid challenge technique as long as hemodynamic parameters (blood pressure, heart rate, pulse pressure variation) continue to improve 1

Exception: Cirrhosis with Sepsis-Induced Hypotension

If the patient has underlying cirrhosis AND sepsis-induced hypotension:

• Use 5% albumin at 0.5-1.0 g/kg administered over 3 hours as the preferred resuscitation fluid 2, 4
• This is superior to crystalloids for reversing hypotension and improving short-term survival in this specific population 2
• Avoid 20% albumin in this setting, as it achieves faster MAP >65 mmHg but requires discontinuation in 22% of patients due to pulmonary complications (pulmonary edema, decreased oxygenation) 4

Critical Safety Considerations

Major risks of albumin administration include:

• Fluid overload and pulmonary edema, particularly in patients with compromised cardiac or pulmonary function—this is dose-dependent 2, 5
• Paradoxical hypotension can occur with rapid albumin infusion, especially in patients taking ACE inhibitors (11% incidence in cardiac surgery patients) 6
• Anaphylactoid reactions including severe hypotension, bronchospasm, and decreased oxygenation, though rare 7
• In cirrhotic patients with extraperitoneal infections, albumin increases pulmonary edema risk 5-fold (OR 5.17,95% CI 1.62-16.47) 3

When Albumin May Be Considered

Specific indications where albumin has established benefit:

• Large-volume paracentesis (>5L): 8 g albumin per liter of ascites removed, given as 20% or 25% solution after paracentesis completion 1
• Spontaneous bacterial peritonitis: 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1
• Hepatorenal syndrome type 1: Initial dose 1 g/kg for 2 days (maximum 100 g/day), followed by 20-40 g/day in combination with vasoconstrictors 1

Practical Algorithm

1. Identify the cause of hypotension: Assess for hypovolemia, sepsis, cardiac dysfunction, or bleeding 3

2. Determine if cirrhosis is present:

   • No cirrhosis: Use crystalloid boluses 20-30 mL/kg, NOT albumin 1, 2, 3
   • Cirrhosis with sepsis: Use 5% albumin 0.5-1.0 g/kg over 3 hours 2, 4

3. Monitor for fluid overload: Stop albumin immediately if hepatomegaly or pulmonary rales develop; switch to inotropic support 1

4. Initiate vasopressors if needed: If MAP remains <65 mmHg after initial fluid resuscitation, begin norepinephrine rather than additional albumin 1

Key Pitfalls to Avoid

• Do not use albumin to "correct" low serum albumin levels—low albumin is a marker of inflammation and mortality risk, not an indication for infusion 8
• Do not use albumin routinely in general septic shock—it offers no mortality benefit over crystalloids (RR 0.98,95% CI 0.92-1.06) and costs significantly more 2
• Do not continue albumin if signs of volume overload appear—switch immediately to diuretics and inotropic support 1
• Avoid rapid infusion in patients on ACE inhibitors—this increases risk of paradoxical hypotension through bradykinin generation 6

Cost Considerations

• Albumin costs approximately $130 per 25 g vial in the United States 2
• Given lack of superiority over crystalloids in most settings, crystalloids should be the default resuscitation fluid except in the specific cirrhosis-sepsis scenario 2, 3