Discontinue Albumin Immediately in This Patient
Albumin infusion should be stopped immediately in this adult patient with traumatic brain injury, as albumin is contraindicated in TBI and associated with significantly increased mortality. The presence of neutropenia (ANC) does not justify continued albumin use, as albumin has no role in treating neutropenia and the evidence strongly demonstrates harm in head injury patients.
Evidence Against Albumin in Traumatic Brain Injury
The evidence against albumin in TBI is unequivocal and comes from the highest quality sources:
- The SAFE study demonstrated that TBI patients receiving 4% albumin had 63% higher mortality compared to saline (24.5% vs. 15.1%, RR: 1.62, p = 0.009) 1
- At 24-month follow-up, mortality was even worse: 33.2% in the albumin group versus 20.4% in the saline group (RR: 1.63,95% CI: 1.17-2.26, p=0.003) 1
- In severe TBI patients (GCS 3-8), albumin increased mortality to 41.8% versus 22.2% with saline (RR: 1.88,95% CI: 1.31-2.70, p<0.001) 1
Mechanism of Harm
The mechanism by which albumin causes harm in TBI is well-established:
- Albumin causes increased intracranial pressure during the first week after injury, which is the most likely mechanism of increased mortality 2
- The hypotonic nature of 4% albumin (real osmolality ~270 mOsm/kg) contributes to cerebral edema by causing fluid shifts into damaged brain tissue 3, 4
- Albumin was also associated with a six-fold higher rate of pulmonary edema in brain-injured patients 3
Current Guideline Recommendations
Multiple high-quality guidelines explicitly contraindicate albumin in TBI:
- The 2024 International Multidisciplinary Perioperative Quality Initiative strongly recommends against albumin use in traumatic brain injury patients based on moderate quality evidence 3, 4
- The 2024 International Collaboration for Transfusion Medicine Guidelines state that albumin should not be used in critically ill patients for volume replacement or to increase serum albumin levels 3
- Current TBI management guidelines explicitly state: "We do not suggest using 4% albumin solution in severe TBI patients" 4
Management of Neutropenia
The neutropenia (ANC) in this patient requires separate management unrelated to albumin:
- Neutropenia is defined as neutrophil count ≤500 cells/mm³ or ≤1000 cells/mm³ with predicted decrease to ≤500 cells/mm³ 3
- Fever in neutropenic patients requires empiric antibiotics with antipseudomonal coverage (cefepime, ceftazidime, or carbapenem), not albumin 3
- Colony-stimulating factors should be considered in neutropenic patients with predicted worsening course, not albumin 3
- Albumin has no established role in treating neutropenia or improving outcomes in neutropenic patients 3
Appropriate Fluid Management for This Patient
After stopping albumin, appropriate fluid management should include:
- Use isotonic crystalloids (0.9% saline or buffered isotonic solutions like Plasma-Lyte) as first-line fluid therapy 3, 5, 6
- Buffered isotonic solutions may be preferable to avoid hyperchloremic metabolic acidosis with prolonged 0.9% saline use 3, 6
- Avoid hypotonic solutions (Ringer's lactate, Ringer's acetate) as they worsen cerebral edema 3, 5, 6
- Maintain euvolemia while avoiding both hypovolemia and hypervolemia, as positive fluid balance worsens outcomes in brain injury 3
Critical Pitfalls to Avoid
- Do not continue albumin to "correct" low serum albumin levels—hypoalbuminemia in TBI is a marker of acute-phase response and IL-1 mediated endothelial permeability changes, not a treatment target 7, 8
- Do not confuse the contraindication of 4% albumin with potential use of hyperoncotic (20-25%) albumin, which has limited evidence and remains controversial 9
- Do not use albumin for any indication in this patient population—the only conditional uses of albumin are for cirrhosis with large-volume paracentesis or spontaneous bacterial peritonitis, neither of which apply here 3