ALBUMIN 

1.  BASIC OVERVIEW

Albumin is the most abundant plasma protein synthesized by the liver (~10–15 g/day).

  • Normal serum level: 3.5–5.0 g/dL
  • Half-life: ~18–20 days

Key Physiological Roles

  1. Oncotic pressure maintenance (~70–80%)
  2. Transport protein
    • Hormones (thyroxine, cortisol)
    • Drugs (e.g., Warfarin, Phenytoin)
  1. Buffering (acid-base)
  2. Antioxidant / anti-inflammatory effects
  3. Endothelial stabilization (glycocalyx protection)

2.  PREPARATIONS & TYPES

Available Forms

Type

Concentration

Characteristics

Iso-oncotic albumin

4–5%

Volume expander (like plasma)

Hyperoncotic albumin

20–25%

Pulls fluid from interstitium

Key Differences

Feature

5% Albumin

20% Albumin

Oncotic pressure

≈ Plasma

↑↑ High

Fluid shift

Minimal

Strong intravascular recruitment

Use

Shock resuscitation

Edema/ascites


3.  PHARMACOKINETICS IN CRITICAL ILLNESS

In ICU Patients:

  • ↑ Capillary leak → albumin escapes into interstitium
  • ↓ Synthesis (sepsis, liver failure)
  • ↑ Catabolism

 Result:

  • Shortened effective half-life
  • Reduced oncotic efficacy

4.  INDICATIONS IN CCM 

A.  SEPTIC SHOCK

 Evidence:

  • SAFE Trial
  • ALBIOS Trial
  • Surviving Sepsis Campaign

Recommendations:

  • Use crystalloids first
  • Add albumin if:
    • Large volumes required
    • Persistent hypoalbuminemia

 SSC (2021):

“Suggest albumin in addition to crystalloids in patients requiring substantial fluid resuscitation”


B.  ARDS

  • Albumin + diuretics → improves oxygenation (temporary)
  • Mechanism:
    • ↓ Extravascular lung water
    • ↑ oncotic pressure

Not routine; selected cases only


C.  TRAUMATIC BRAIN INJURY (TBI)

 Contraindicated

  • SAFE subgroup → ↑ mortality in TBI with albumin
  • Mechanism:
    • ↑ cerebral edema (hypo-osmolar effect)

D.  HYPOVOLEMIC SHOCK

  • Alternative to crystalloids
  • No mortality benefit over saline

 Consider when:

  • Fluid overload risk
  • Hypoalbuminemia

E.  LIVER CIRRHOSIS

1. Large Volume Paracentesis

  • Give albumin if >5 L removed
  • Dose: 6–8 g per L ascitic fluid removed

2. Spontaneous Bacterial Peritonitis (SBP)

  • Prevents renal failure
  • Dose:
    • Day 1: 1.5 g/kg
    • Day 3: 1 g/kg

3. Hepatorenal Syndrome (HRS)

  • Albumin + vasoconstrictor (e.g., Terlipressin)

 Strong guideline-backed indication


F.  HYPOALBUMINEMIA

 Not an indication alone

  • No benefit in:
    • Nutrition
    • Chronic illness
    • ICU hypoalbuminemia correction alone

G.  DRUG BINDING & TOXICITY

  • Low albumin → ↑ free drug fraction
  • Important in ICU drugs:
    • Phenytoin
    • Warfarin

6.  DOSING STRATEGIES

General ICU Use

  • 5%: 250–500 mL bolus
  • 20%: 100 mL over 30–60 min

Target-based therapy:

  • Serum albumin goal (ALBIOS): ~3 g/dL (not routine practice)

7. ADVERSE EFFECTS

Common:

  • Fluid overload (especially 5%)
  • Hypotension (rapid infusion)

Serious:

  • Anaphylaxis (rare)
  • Pulmonary edema
  • Hemodilution

8.  CONTROVERSIES 

 Does albumin improve survival?

 NO (overall ICU population)

 When is albumin clearly beneficial?

✔ Cirrhosis (SBP, HRS, paracentesis)

 Harmful situations?

 TBI