Is the prescribed 20% human albumin appropriate for this patient who requires rapid plasma volume expansion or correction of severe hypo‑albuminemia, given their serum albumin level, fluid balance, cardiac and renal status, and no contraindications such as hypersensitivity, uncontrolled hypervolemia, pulmonary edema, or severe congestive heart failure?

Clinical Verification of Human Albumin 20% Prescription

As a pharmacist verifying a prescription for human albumin 20%, you must confirm the indication is evidence-based and appropriate, as most albumin use remains inappropriate despite clear guidelines restricting its use to specific, well-defined clinical scenarios. 1, 2

Step 1: Verify the Indication is Evidence-Based

APPROVED Indications for Albumin 20% (Strong Evidence)

Cirrhosis-Related Complications:

• Spontaneous bacterial peritonitis (SBP): 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1, 3
• Large-volume paracentesis (>5L): 8 g per liter of ascites removed, administered after procedure completion 1, 3
• Hepatorenal syndrome: Used with vasoconstrictors like terlipressin 1

Severe Burns:

• Total body surface area >30% after first 6 hours of management, targeting serum albumin >30 g/L with doses of 1-2 g/kg/day 4

Plasmapheresis:

• Fluid replacement during procedure 3

CONTRAINDICATED Uses (Reject These Prescriptions)

The following indications should prompt you to contact the prescriber for clarification or alternative therapy:

• Correcting hypoalbuminemia alone without specific complications 1, 2
• Routine volume replacement in critically ill patients (crystalloids are first-line) 4, 1
• Cardiovascular surgery (routine use) 1
• Uncomplicated ascites in cirrhosis 1
• Nutritional supplementation 5, 6
• Nephrotic syndrome without acute complications 1
• Intradialytic hypotension as routine therapy 1
• Neonatal critical care (explicitly not recommended) 7

Step 2: Assess Patient-Specific Contraindications

Absolute contraindications requiring prescription rejection:

• Uncontrolled hypervolemia or fluid overload 1, 8
• Pulmonary edema 1, 8
• Severe congestive heart failure 8
• Known hypersensitivity to albumin 8

High-risk situations requiring dose verification:

• Doses exceeding 87.5 g (>4×100 mL of 20%) associated with worse outcomes in cirrhosis due to fluid overload 1
• Existing fluid overload with hypotension (albumin will worsen overload, not improve it) 1
• Cardiac dysfunction requiring careful monitoring 4

Step 3: Verify Dosing and Administration

Check the prescribed dose against these evidence-based regimens:

Indication	Correct Dose	Timing
SBP	1.5 g/kg then 1.0 g/kg	Within 6 hours, then day 3 [1]
Large-volume paracentesis	8 g/L ascites removed	After procedure [1]
Burns (TBSA >30%)	1-2 g/kg/day	After first 6 hours [4]
Hepatorenal syndrome	Variable with vasoconstrictors	Per protocol [1]

Administration rate:

• Maximum 2 mL/minute in hypoproteinemic patients to prevent circulatory embarrassment and pulmonary edema 8
• Can be given undiluted or diluted in 0.9% NaCl or 5% dextrose 8
• Contains NO potassium (safe in hyperkalemia) 9

Step 4: Common Pitfalls to Avoid

Critical errors that lead to inappropriate albumin use:

1. Daily albumin for chronic hypoalbuminemia: This is futile and expensive ($3,900/month) without evidence of benefit 1, 2

2. Using albumin to "mobilize fluid" with diuretics: No evidence supports this practice; optimize diuresis with appropriate diuretic dosing instead 1

3. Prescribing for "low albumin" without specific complications: Hypoalbuminemia is a biomarker of disease severity, not a treatment target 2, 6

4. Giving albumin for volume expansion when crystalloids are appropriate: Crystalloids are first-line for most volume resuscitation; albumin costs ~$130 per 25g without proven superiority 1, 3

Step 5: Document Your Clinical Decision

If prescription is appropriate:

• Verify indication matches evidence-based use
• Confirm dose and administration rate
• Ensure monitoring plan for fluid overload, blood pressure, and renal function 1

If prescription is inappropriate:

• Contact prescriber immediately with specific guideline references
• Suggest crystalloid alternatives for volume expansion 4, 1
• Recommend addressing underlying cause of hypoalbuminemia rather than treating the number 2
• Document intervention and outcome

Monitoring Requirements During Administration

Mandatory monitoring per FDA and guidelines:

• Circulatory overload surveillance (especially in cirrhosis patients) 1, 8
• Blood pressure (paradoxical hypotension can occur) 1
• Fluid balance and signs of pulmonary edema 1, 8
• Renal function in patients with rising creatinine 1

Documented complications requiring vigilance:

• Fluid overload and pulmonary edema 1
• Hypotension 1
• Hemodilution requiring RBC transfusion 1
• Anaphylaxis 1