Guidelines for Albumin Injection in Volume Expansion and Shock Treatment

General Recommendations for Albumin Use

Isotonic crystalloids should be used as first-line therapy for volume expansion in most patients at risk for or with acute kidney injury, while albumin should be reserved for specific clinical scenarios where its benefits outweigh potential risks, as recommended by the American Journal of Kidney Diseases 1, 2
Albumin is not recommended as first-line treatment for volume expansion in most clinical scenarios, with crystalloid solutions being preferred due to similar efficacy, lower cost, and fewer potential adverse effects, according to the American Journal of Kidney Diseases and Anaesthesia 1, 3
In the absence of hemorrhagic shock, isotonic crystalloids rather than colloids (including albumin) are suggested as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI, with a Grade 2B recommendation from KDIGO 1, 2, 4
Albumin resuscitation has been associated with harm in patients with traumatic brain injury and should be avoided in that setting, as reported by the American Journal of Kidney Diseases 1, 2

Specific Indications for Albumin Use

Intravenous albumin administration is beneficial for prevention of renal failure and death in patients with spontaneous bacterial peritonitis, as recommended by the American Journal of Kidney Diseases 1
Intravenous albumin administration is beneficial for prevention of renal failure and death in patients with large-volume paracentesis, according to the American Journal of Kidney Diseases 1, 2
For hepatorenal syndrome, diagnostic criteria include lack of improvement in renal function after volume expansion with albumin (1 g/kg/d up to 100 g/d) for at least 2 days and withdrawal of diuretic therapy, as reported by the American Journal of Kidney Diseases 1, 2

Albumin in Septic Shock

In comparison with crystalloids, it is probably not recommended in cases of sepsis or septic shock to use albumin as first-line treatment to reduce mortality or renal replacement therapy requirement, with a Grade 2- recommendation from Anaesthesia 5, 6
While some studies showed improved circulatory function and lower volume requirements with albumin in septic shock, no definitive mortality benefit has been demonstrated, according to Anaesthesia 7

Albumin in Hemorrhagic Shock

There has been no published study specifically focusing on the benefit of albumin during hemorrhage, and the few studies based on sub-group analysis of trauma patients without traumatic brain injury showed no benefit, as reported by Anaesthesia 3, 8
In patients with hemorrhagic shock, it is recommended to use balanced crystalloids rather than 0.9% NaCl as first-line fluid therapy to reduce mortality and/or adverse renal events, with a Grade 2+ recommendation from Anaesthesia 3, 8
In children with severe malaria presenting with coma and features of shock, human albumin solution may be considered the resuscitation fluid of choice, according to the BMJ 9

Albumin Administration in Specific Clinical Scenarios

Indications for Albumin Use

The American Association for the Study of Liver Diseases recommends albumin for large-volume paracentesis (LVP) at a dose of 8 g/L of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction 10, 11
For paracentesis of >5 L of ascites, albumin is more effective than other plasma expanders in preventing circulatory dysfunction 12, 13
The American Thoracic Society indicates that IV albumin is indicated in patients with spontaneous bacterial peritonitis to prevent renal failure and reduce mortality 14
Albumin is the volume expander of choice in hospitalized patients with cirrhosis and ascites presenting with acute kidney injury 10
For hepatorenal syndrome with acute kidney injury (HRS-AKI), terlipressin is the vasoactive drug of choice, and concurrent albumin can be considered based on the patient's volume status 10
Norepinephrine can be used in the treatment of HRS-AKI, but albumin administration should be guided by the patient's volume status rather than automatically given 10
The American Association for the Study of Liver Diseases recommends that albumin should not be used in patients with cirrhosis and uncomplicated ascites 10
Vasoconstrictors (including norepinephrine) should not be used in the management of uncomplicated ascites, after large-volume paracentesis, or in patients with spontaneous bacterial peritonitis 10
In some critically ill patients, albumin administration has been associated with pulmonary edema 14

Albumin 5% Reconstitution for Volume Expansion

Indications and Usage

The American Association for the Study of Liver Diseases recommends administering 8 g of albumin per liter of ascites removed after large-volume paracentesis (>5 liters) 15, 16, 17
Albumin 25% is indicated for paracentesis of gran volumen, shock hipovolémico in patients with normal hydration or interstitial edema, hypoproteinemia with or without edema, and acute respiratory distress syndrome with volume overload and hypoproteinemia 15, 16, 17

Administration Considerations

The European Association for the Study of the Liver suggests that albumin should be administered intravenously, and the solution should be inspected visually for particles or discoloration before administration 17

Limitations and Precautions

The American College of Critical Care Medicine states that albumin is not indicated as first-line treatment for volume expansion in most clinical scenarios, due to similar efficacy, lower cost, and fewer potential adverse effects of isotonic crystalloids, except in specific indications such as large-volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome 17

Albumin Dosing for Volume Expansion in Adults

Specific Clinical Scenarios with Recommended Albumin Doses

The European Association for the Study of the Liver recommends a maximum daily dose of albumin not to exceed 100 g for spontaneous bacterial peritonitis 18
The American Burn Association suggests a dose of 1-2 g/kg/day to maintain serum albumin levels >30 g/L for burns with TBSA >30% 19
The American Burn Association recommends administering 5% albumin solution after the first 6 hours of management for burns with TBSA >30% 20
The American Burn Association suggests that early administration of 5% albumin (8-12 hours post-burn) may be beneficial for pediatric burns (TBSA >15%) 19

Important Caveats

The European regulatory agencies contraindicate the use of hydroxyethyl starches in severe burns 21
The European regulatory agencies also support the contraindication of hydroxyethyl starches in severe burns 20

Albumin Concentration for Fluid Resuscitation

General Principles by Clinical Context

The American Thoracic Society recommends 5% albumin as the standard concentration for volume resuscitation in critically ill patients, providing volume expansion without excessive oncotic pull 22, 23
The SAFE trial demonstrated equivalent outcomes to crystalloids in general ICU populations using 4% albumin 22, 23
The European Society of Anaesthesiology recommends 20% albumin for septic shock, targeting serum albumin >30 g/L, but notes no mortality benefit despite improved hemodynamics 24

Burn Resuscitation

The American Burn Association recommends 5% albumin for severe burns (TBSA >30%) after the first 6-8 hours of management, with dosing targets of 1-2 g/kg/day to maintain serum albumin levels >30 g/L 25, 26
Early administration of 5% albumin at 8-12 hours post-burn in pediatric burns (TBSA >15%) decreased crystalloid requirements and hospital length of stay 25

Practical Considerations

The American Association for the Study of Liver Diseases recommends 20% albumin for cirrhotic patients with sepsis-induced hypotension, with higher shock reversal rates but increased pulmonary complications 27
The American Thoracic Society notes that 5% albumin has a lower risk of volume overload and pulmonary edema compared to 20-25% concentrations 27

Critical Caveats

The Brain Injury Foundation advises against using albumin in traumatic brain injury due to increased mortality risk (RR 1.62) 22, 23
The European Society of Anaesthesiology states that crystalloids remain first-line therapy for most resuscitation scenarios, with albumin reserved for specific indications where benefits outweigh costs and risks 22, 23