Guide Proper Use of Albumin

Albumin shortages and high costs continue to plague hospitals...and pharmacists are key to improving stewardship.

Evidence suggests that pharmacist intervention reduces inappropriate use by over 50%...and leads to major cost savings.

Consider requiring an albumin order set that includes indications and criteria for appropriate use.

For example, save albumin for patients with septic shock who aren’t responding to an adequate trial of crystalloids.

Also include certain indications for patients with acute decompensated liver disease.

For instance, use albumin to decrease kidney injury or mortality in patients with spontaneous bacterial peritonitis PLUS certain risks...BUN over 30 mg/dL, serum creatinine above 1 mg/dL, or total bilirubin over 4 mg/dL.

Also give albumin after paracentesis...but only if more than 5 L is removed. This helps prevent circulatory dysfunction.

Include patients with hepatorenal syndrome-acute kidney injury (HRS-AKI) on albumin order sets. These patients typically have cirrhosis and ascites...and develop AKI due to splanchnic vasodilation.

Give albumin along with a vasoconstrictor...norepinephrine or terlipressin...for patients with HRS-AKI to improve kidney perfusion.

But don’t give albumin to patients with decompensated cirrhosis simply to raise low albumin levels. This doesn’t improve outcomes.

When giving albumin in liver disease, generally use 25%. Its oncotic pressure draws fluid into the intravascular space.

Save 5% for septic shock that’s unresponsive to crystalloids.

If 5% albumin is in short supply, it’s okay to dilute the 25% product with normal saline (NaCl 0.9%) or D5W. But avoid diluting albumin with sterile water due to risk for hemolysis.

Typically max the 25% albumin rate at 2 mL/min for nonemergent limit fluid overload. Monitor for respiratory distress, hypertension, etc...especially with heart failure or other risks.

Also monitor for hypernatremia with ongoing albumin use. The sodium content is similar to normal saline.

Advise nurses to use vented tubing when administering albumin that’s in a glass prevent flow issues.

Get our resource, Decompensated Chronic Liver Failure, for albumin doses...and more on hepatic encephalopathy, ascites, etc.

Key References

  • Hepatology. 2021 Aug;74(2):1014-1048
  • Am J Health Syst Pharm. 2023 Apr 4. doi: 10.1093/ajhp/zxad070
  • Ann Pharmacother. 2021 Jan;55(1):44-51
  • J Clin Pharm Ther. 2021 Aug;46(4):887-894
  • Medication pricing by Elsevier, accessed May 2023
Hospital Pharmacist’s Letter. June 2023, No. 390620

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