Critical Care: Guidelines and Consensus Statements

Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines

Jeannie Callum, Nikolaos J. Skubas, Aarti Bathla, et al

Chest 2024; 166: 321-338

Background

Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis.

Study Design and Methods

Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation.

Results

The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused.

Interpretation

Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.

1. In critically ill adult patients (excluding patients with thermal injuries and ARDS), intravenous albumin is not suggested for first-line volume replacement or to increase serum albumin levels (Conditional Recommendation, Moderate Certainty of Evidence of Effect).

2. In critically ill adult patients with thermal injuries or ARDS, intravenous albumin is not suggested for volume replacement or to increase serum albumin level(Conditional Recommendation, Very Low Certainty of Evidence of Effect).

3. In critically ill adult patients, intravenous albumin in conjunction with diuretics is not suggested for removal of extravascular fluid (Conditional Recommendation, Very Low Certainty of Evidence of Effect).

4. In pediatric patients with infection and hypoperfusion, intravenous albumin is not recommended to reduce mortality (Strong Recommendation, Low Certainty of Evidence of Effect).

5. In preterm neonates (≤ 36 weeks) with low serum albumin levels and respiratory distress, intravenous albumin is not suggested to improve respiratory function(Conditional Recommendation, Very Low Certainty of Evidence of Effect).

6. In preterm neonates (≤ 32 weeks or ≤ 1,500 g) with or without hypoperfusion, intravenous albumin is not suggested for volume replacement (Conditional Recommendation, Very Low Certainty of Evidence of Effect).

7. In patients undergoing kidney replacement therapy, intravenous albumin is not suggested for prevention or treatment of intradialytic hypotension or for improving ultrafiltration (Conditional Recommendation, Very Low Certainty of Evidence of Effect).

8. In adult patients undergoing cardiovascular surgery, intravenous albumin is not suggested for priming the cardiovascular bypass circuit or volume replacement(Conditional Recommendation, Moderate Certainty of Evidence of Effect).

9. In pediatric patients undergoing cardiovascular surgery, intravenous albumin is not suggested for priming the cardiovascular bypass circuit or volume replacement(Conditional Recommendation, Very Low Certainty of Evidence of Effect).

10. In patients with cirrhosis and ascites undergoing large-volume paracentesis (> 5L), intravenous albumin is suggested to prevent paracentesis-induced circulatory dysfunction (Conditional Recommendation, Very Low Certainty of Evidence of Effect).

11. In patients with cirrhosis and spontaneous bacterial peritonitis, intravenous albumin is suggested to reduce mortality (Conditional Recommendation, Low Certainty of Evidence of Effect).

12. In patients with cirrhosis and extraperitoneal infections, intravenous albumin is not suggested to reduce mortality or kidney failure (Conditional Recommendation, Low Certainty of Evidence of Effect).

13. In hospitalized patients with decompensated cirrhosis with hypoalbuminemia (< 30 g/L), repeated intravenous albumin to increase albumin levels to > 30 g/L is not suggested to reduce infection, kidney dysfunction, or death (Conditional Recommendation, Low Certainty of Evidence of Effect).

14. In outpatients with cirrhosis and uncomplicated ascites despite diuretic therapy, intravenous albumin is not routinely suggested to reduce complications associated with cirrhosis (Conditional Recommendation, Low Certainty of Evidence of Effect).