In a patient with ascites undergoing large-volume paracentesis, what albumin infusion (type and dose) should be administered?

Albumin Infusion Protocol for Large-Volume Paracentesis in Ascites

Administer 8 grams of albumin per liter of ascitic fluid removed when the total volume exceeds 5 liters, using either 20% or 25% albumin solution infused after—not during—the paracentesis is completed. 1

Mandatory Albumin Replacement (>5 Liters Removed)

• For paracentesis removing more than 5 liters, albumin replacement at 8 g per liter is mandatory and represents a strong, high-quality recommendation from multiple international hepatology societies. 1, 2, 3
• This translates to approximately 100 mL of 20% albumin solution for every 3 liters of ascitic fluid removed. 2, 3
• For example, if 8 liters are drained, administer 64 grams total (320 mL of 20% albumin or 256 mL of 25% albumin). 1, 3

Optional Albumin Replacement (<5 Liters Removed)

• For paracentesis removing less than 5 liters, albumin is not mandatory in uncomplicated cases. 1, 2
• However, consider albumin at 8 g/L even for volumes <5 liters in high-risk patients with acute-on-chronic liver failure or elevated risk of post-paracentesis acute kidney injury. 1, 2, 3
• In low-risk patients with <5 L removed, synthetic plasma expanders (150–200 mL of gelofusine or Haemaccel) are acceptable alternatives, though inferior to albumin. 2, 4

Administration Protocol

Timing and Rate

• Infuse albumin after paracentesis completion, not during the procedure—this timing is critical for preventing post-paracentesis circulatory dysfunction (PICD). 2, 3
• Administer over 1–2 hours to avoid volume overload, particularly in patients with cirrhotic cardiomyopathy. 2

Formulation

• Use 20% or 25% albumin solution (hyperoncotic formulations); 5% albumin is inadequate for this indication. 1, 2, 4
• 25% albumin contains 25 grams per 100 mL; 20% albumin contains 20 grams per 100 mL. 3

Clinical Rationale: Why Albumin Matters

• Without albumin replacement, approximately 21% of patients develop renal impairment versus 0% with albumin. 2
• PICD occurs in up to 80% of patients without volume expansion but only 18.5% when albumin is used. 2
• Albumin prevents hyponatremia (42% reduction), PICD (61% reduction), and mortality (36% reduction) compared to alternative plasma expanders. 2
• The severity of PICD inversely correlates with patient survival, making prevention essential. 2

Common Pitfalls to Avoid

Underdosing Albumin

• Do not reduce the dose below 8 g/L—underdosing is associated with significantly increased rates of PICD and renal complications. 2
• A 2020 study attempted 6.5 g/L dosing and found no difference in adverse outcomes compared to 8.3 g/L, but this lower dose remains below guideline recommendations and should not be adopted. 5

Using Normal Saline Instead

• Never substitute normal saline for albumin—saline contains 154 mmol/L sodium and will worsen salt retention and ascites. 4
• Normal saline is explicitly contraindicated in ascites management. 4

Confusing with SBP Dosing

• Do not use the spontaneous bacterial peritonitis (SBP) albumin protocol for routine paracentesis—SBP requires a different weight-based regimen (1.5 g/kg within 6 hours, then 1 g/kg on day 3). 1, 4, 3

Leaving Drains Overnight

• Do not leave drainage catheters in place overnight after completing paracentesis. 2

Post-Paracentesis Management

Diuretic Therapy

• After large-volume paracentesis, resume or initiate diuretic therapy to prevent re-accumulation: spironolactone 100–400 mg/day plus furosemide 40–160 mg/day in a 100:40 mg ratio. 2

Sodium Restriction

• Maintain dietary sodium restriction to ≤2 g sodium/day (approximately 5 g salt/day). 2, 4

Monitoring (6-Day Window)

• Check daily serum creatinine to detect acute kidney injury. 2
• Monitor daily serum sodium for hyponatremia. 2
• Assess plasma renin activity if available—a >50% rise from baseline signals early PICD. 2

Evidence Strength

The 2021 British Society of Gastroenterology/British Association for the Study of the Liver guidelines provide the highest-quality, most recent evidence supporting the 8 g/L dose for >5 L paracentesis (high-quality evidence, strong recommendation). 1 This is reinforced by multiple international societies including the American Association for the Study of Liver Diseases, European Association for the Study of the Liver, and Korean Association for the Study of the Liver, all converging on the same 6–8 g/L range with 8 g/L as the standard. 2, 3

Human albumin is FDA-approved for "removal of ascitic fluid from a patient with cirrhosis" to support blood volume when paracentesis causes cardiovascular changes or hypovolemic shock. 6