Role of 20% Albumin in the ICU

Evidence-Based Indications for 20% Albumin

The American Thoracic Society recommends administering 8g of 20% albumin per liter of ascites removed when removing >5 liters to prevent post-paracentesis circulatory dysfunction, which leads to renal impairment in patients with cirrhosis 4
The American Association for the Study of Liver Diseases suggests infusing 20% or 25% albumin solution after paracentesis completion in patients with cirrhosis 3
The European Association for the Study of the Liver recommends a dose of 1.5g/kg of 20% albumin within 6 hours of diagnosis of spontaneous bacterial peritonitis, followed by 1.0g/kg on day 3 in patients with cirrhosis 4
The use of 20% albumin in combination with vasoconstrictors (terlipressin) is recommended for improved outcomes in patients with hepatorenal syndrome 3
The ALBIOS trial showed a mortality benefit in the septic shock subgroup (OR 0.87, 95% CI 0.77-0.99) when 20% albumin was used to maintain elevated serum albumin levels in patients with septic shock 1, 2, 5
One meta-analysis found 90-day mortality benefit in septic shock (OR 0.81, 95% CI 0.67-0.97) with the use of 20% albumin 1, 2

The Society of Critical Care Medicine does not recommend 20% albumin for routine volume replacement in critically ill adults, as it is not superior to crystalloids for general resuscitation 7, 3
The American Heart Association does not recommend 20% albumin for routine use in cardiovascular surgery, as the largest trial (1,386 patients) showed increased bleeding, resternotomy, and infection rates with albumin 4, 3
The National Institute of Diabetes and Digestive and Kidney Diseases does not recommend 20% albumin for treatment of low serum albumin without other specific indications, as serum concentration does not reflect albumin function 3
The American Academy of Pediatrics found excess mortality with albumin bolus strategy in a large trial in children with febrile illness and hypoperfusion 7

The Surviving Sepsis Campaign recommends balanced crystalloids (Ringer's lactate) as first-line for fluid resuscitation in sepsis/septic shock, with consideration of 20% albumin when large volumes of crystalloids are needed and serum albumin is low 1, 2, 5, 6
The cost of 20% albumin is approximately $130/25g USD, significantly more expensive than crystalloids, and must be weighed against potential benefits in specific clinical scenarios 3
The cost of thrice-weekly albumin for hemodialysis patients would be ~$20,000/patient/year 7

The American Society of Health-System Pharmacists recommends monitoring for fluid overload, hypotension, hemodilution requiring RBC transfusion, anaphylaxis, and peripheral gangrene from dilution of natural anticoagulants with the use of 20% albumin 3
One observational study suggested increased renal failure risk with 20% albumin in shock, though RCTs and meta-analyses have not confirmed this 1, 2, 5