Intravenous Albumin: Indications, Dosing, and Precautions
Primary Recommendation
Albumin should NOT be used for first-line volume replacement or to correct low serum albumin levels in critically ill adult patients, with the exception of specific cirrhosis-related complications where it has proven mortality benefit. 1
Evidence-Based Indications
Strong Indications (Moderate to High Quality Evidence)
Cirrhosis with Large-Volume Paracentesis (>5L)
- Administer 8g albumin per liter of ascites removed using 20% or 25% solution 2, 3, 4
- Give after the procedure to prevent post-paracentesis circulatory dysfunction 2
Spontaneous Bacterial Peritonitis in Cirrhosis
- Give 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 2, 5, 4
- This regimen reduces renal dysfunction by 72% and mortality by 47% 2
Hepatorenal Syndrome Type 1
- Start with 1 g/kg/day for 2 days (maximum 100 g/day), then continue 20-40 g/day with vasoconstrictor therapy 5, 4
Sepsis-Induced Hypotension in Cirrhotic Patients (Exception to General Rule)
- Use 5% albumin at 0.5-1.0 g/kg over 3 hours as the preferred resuscitation fluid 5
- 5% albumin is superior to crystalloids for reversing hypotension and improving short-term survival in this specific population 5
Conditional/Weak Indications (Low to Very Low Quality Evidence)
Neonatal Hemolytic Disease
- Give 1 g/kg body weight approximately 1 hour prior to exchange transfusion to bind free bilirubin and reduce kernicterus risk 3
- Exercise caution in hypervolemic infants 3
Plasmapheresis Fluid Replacement
- Moderate quality evidence supports albumin use for fluid replacement during therapeutic apheresis 4
Situations Where Albumin is NOT Recommended
General Critical Care (Excluding Burns and ARDS)
- Do NOT use albumin for first-line volume replacement or to increase serum albumin levels 1
- Crystalloids (balanced crystalloids like lactated Ringer's or Plasma-Lyte) are preferred 5
- Multiple large trials (SAFE, ALBIOS, EARSS) show no mortality benefit compared to crystalloids 5
Cardiovascular Surgery
- Do NOT use albumin for priming cardiopulmonary bypass circuits or volume replacement in adults or children 6
- A meta-analysis of 43 trials found no mortality benefit, no difference in kidney failure, blood loss, or ICU length of stay 6
- The largest trial showed increased morbidity with albumin, including higher rates of bleeding, resternotomy, and infection 6
Intradialytic Hypotension
- Do NOT use albumin routinely due to high costs (~$20,000/patient/year) and limited evidence of benefit 1, 5
- Prefer alternative strategies: higher dialysate calcium, lower dialysate temperature, individualized ultrafiltration rates 5
Hypoalbuminemia Without Specific Indication
- Do NOT administer albumin solely to correct low serum albumin levels 1, 2
- Low albumin is a prognostic marker of illness severity, not a treatment target 2, 6
- Albumin infusion cannot reverse underlying causes (inflammatory cytokines suppressing synthesis, transcapillary loss) 2
Pediatric Critical Care
- Do NOT use albumin in children with febrile illness and hypoperfusion 5
- The FEAST trial demonstrated excess mortality with albumin bolus in this population 5
Dosing Regimens by Indication
Hypovolemic Shock (When Indicated)
- Total dose should not exceed 2 g/kg body weight in the absence of active bleeding 3
- Plasbumin-25 (25% albumin) is hyperoncotic and expands plasma volume by 3-4 times the volume administered 3
- If patient is dehydrated, additional crystalloids must be given, or use 5% albumin instead 3
Burns (Beyond 24 Hours)
- Aim to maintain plasma albumin concentration at 2.5 ± 0.5 g/100 mL 3
- Target plasma oncotic pressure of 20 mm Hg (equivalent to total plasma protein 5.2 g/100 mL) 3
- Use Plasbumin-25 (25% albumin) for this indication 3
Hypoproteinemia with Edema
- Usual daily dose: 50-75g for adults, 25g for children 3
- Rate of administration should not exceed 2 mL/minute to prevent circulatory embarrassment and pulmonary edema 3
Cardiopulmonary Bypass (If Used Despite Recommendations)
- Adjust albumin and crystalloid pump prime to achieve hematocrit of 20% and plasma albumin concentration of 2.5 g/100 mL 3
Administration Guidelines
Route and Preparation
- Always administer by intravenous infusion 3
- May be given undiluted or diluted in 0.9% sodium chloride or 5% dextrose in water 3
- For sodium restriction, use undiluted or dilute only in sodium-free solutions like 5% dextrose 3
- Use only 16-gauge needles or dispensing pins for 20 mL vial sizes and larger 3
Rate of Administration
- In hypoproteinemic patients with normal blood volumes, do not exceed 2 mL/minute 3
- More rapid injection may precipitate circulatory embarrassment and pulmonary edema 3
Critical Safety Precautions
Major Adverse Effects
- Fluid overload and pulmonary edema (dose-dependent) 1, 2
- Paradoxical hypotension 1
- Hemodilution requiring RBC transfusion 1
- Anaphylaxis 1
- Peripheral gangrene from dilution of natural anticoagulants 1
High-Risk Populations
- Patients with cirrhosis have increased capillary permeability and compromised lymphatic drainage, increasing fluid overload risk 5
- Elderly hypertensive patients require smaller boluses (250-500 mL) with frequent reassessment 5
- Patients with compromised cardiac or pulmonary function are at higher risk for pulmonary edema 5
Monitoring Requirements
- Monitor hemodynamic response continuously 3
- Watch for signs of fluid overload: hepatomegaly, pulmonary rales 5
- If volume overload develops, discontinue albumin immediately and switch to inotropic support 5
- If MAP remains <65 mmHg after initial crystalloid challenge, start norepinephrine rather than adding more albumin 5
Common Pitfalls to Avoid
Do NOT use serum albumin concentration as an indication for albumin administration 2, 6
- Low albumin reflects disease severity, not a correctable deficit 2
- Postoperative hypoalbuminemia (10-15 g/L decrease) is expected and does not require correction 1, 6
Do NOT assume albumin provides superior volume expansion over crystalloids in general critical care 6, 5
- The largest trials show no benefit and potential harm 6
Do NOT exceed 87.5g total dose 6
- Higher doses increase risk of fluid overload and worse outcomes 6
Do NOT use albumin to reduce edema or improve nutrition 2
- It does neither effectively and may worsen fluid overload 2
Cost Considerations
Economic Impact
- Albumin costs approximately $130 per 25g vial in the United States 1, 5
- Acquisition cost is likely a fraction of total healthcare expenditure 1
- Given lack of superiority over crystalloids in most settings, crystalloids should be the default resuscitation fluid 5
- Implementation of evidence-based guidelines can reduce inappropriate albumin use 4