Bedside Snapshot
- Use It For
- Large-volume paracentesis (>5 L); SBP with antibiotics; hepatorenal syndrome with a vasoconstrictor; hypovolemia or septic shock after large crystalloid volumes (not first-line)
- Adult Dose
- Paracentesis >5 L: 6–8 g per liter removed IV
- SBP: 1.5 g/kg IV day 1, then 1 g/kg day 3
- HRS-AKI: 20–40 g/day IV with a vasoconstrictor, adjusted daily to volume status; reduce or stop for overload
- Pediatric Dose
- Hypovolemic shock: 5% 12–20 mL/kg IV, repeat after 15–30 min if needed (max 2 g/kg/day). Crystalloid, not albumin, for initial sepsis resuscitation
- Onset / Duration
- IV: immediate (25% recruits tissue fluid over about 15 min) / hours, longer in hypovolemia and shorter with capillary leak
- Do Not Give / Hold If
- Albumin allergy; severe anemia or heart failure with normal or high volume; TBI resuscitation; stop for dyspnea, crackles, JVD or falling SpO₂
- Watch For
- Pulmonary edema (crackles, falling SpO₂); anaphylaxis (hypotension, wheeze, urticaria); hemodilution (falling hemoglobin); rebleeding as BP rises after trauma or surgery
- Reversal / Rescue
- No reversal: stop the infusion. Overload: sit up, oxygen, loop diuretic per protocol. Anaphylaxis: IM epinephrine and standard care
- Must Remember
- Never dilute 20–25% albumin with Sterile Water for Injection: it causes fatal hemolysis and kidney failure. Use 0.9% NaCl or D5W; start within 4 hr of spiking and discard any remainder
Indications
ED / ICU / Transport
- Large-volume paracentesis (LVP, >5 L) in cirrhosis: PPCD (paracentesis-induced circulatory dysfunction; ICTMG Recommendation 10) is the post-tap drop in effective blood volume. It leads to kidney injury, hyponatremia and death. Albumin prevents it
- Spontaneous bacterial peritonitis (SBP): it goes in with antibiotics (e.g., ceftriaxone) to protect the kidneys and cut mortality. The benefit is clearest when creatinine >1 mg/dL, BUN >30 mg/dL or bilirubin >5 mg/dL. ICTMG 2024 suggests albumin to reduce mortality (Recommendation 11; conditional, low certainty). AGA 2024 best-practice advice says it may be considered. Not for other infections in cirrhosis (pneumonia, urinary tract, skin)
- Acute kidney injury (AKI) in cirrhosis with ascites: albumin is the volume expander of choice when hypovolemia is suspected. Diuretics and nephrotoxins get stopped, and the dose follows volume status. A fixed 2-day albumin challenge is no longer required to diagnose hepatorenal syndrome (ADQI/ICA 2024)
- Hepatorenal syndrome with AKI (HRS-AKI): pair it with a vasoconstrictor. Terlipressin is preferred, or norepinephrine in the ICU
- Sepsis or septic shock after large crystalloid volumes, or with cirrhosis: an adjunct only. SSC 2026 suggests crystalloids alone for most adults
- Hypovolemia or hypovolemic shock when a colloid is appropriate: the FDA label covers it, but it is not first-line. Crystalloid comes first, and blood products go in for hemorrhage
- Major burns (adults, at least 20% TBSA): this is not routine. ABA 2024 recommends considering albumin, especially in larger burns, to lower resuscitation fluid volume and improve urine output. It did not test survival. ICTMG 2024 suggests against albumin for volume replacement in thermal injury (Recommendation 2; conditional, very low certainty). Give it only under a burn-center protocol, titrated to urine output. Never prehospital. The FDA labels specify use after the first 24 hr, so they differ from these guidelines.
Other Uses
- Therapeutic plasma exchange: 5% albumin as replacement fluid
- Hemolytic disease of the newborn: 25% albumin before or during exchange transfusion. It binds unconjugated bilirubin.
- Other labeled uses: cardiopulmonary bypass priming, nephrotic edema with diuretics, and severe ovarian hyperstimulation syndrome. Current guidelines do not support routine use for bypass priming or dialysis hypotension (ICTMG Recommendations 7, 8 and 9)
- Acute respiratory distress syndrome (ARDS): the label includes albumin with diuretics for interstitial pulmonary edema and low protein. ICTMG 2024 suggests against albumin in critically ill adults with ARDS, both for volume replacement and to raise serum albumin. It also suggests against albumin with diuretics to remove fluid (Recommendations 2 and 3)
Not for a low lab value: Hypoalbuminemia is on the label, but the guidelines do not back treating the number. A low serum albumin is no reason to give it. Dose to circulating volume, not to plasma albumin (FLEXBUMIN label, section 2.1). Repeated infusions to a target in decompensated cirrhosis did not cut infection, kidney dysfunction or death. They did add serious adverse events, mainly a numerical rise in pulmonary edema (ICTMG Recommendations 1 and 13). See Albumin (lab value).
Composition
Source: FLEXBUMIN 5% and FLEXBUMIN 25% labels (DailyMed), section 11 (Description). Sodium and stabilizer values are given for each product.
| Component | 5% per liter | 25% per liter | Comparison to Plasma |
|---|---|---|---|
| Albumin | 50 g (5 g/100 mL) | 250 g (25 g/100 mL) | 5% is near the plasma albumin concentration; 25% is far above it |
| Oncotic effect | About iso-oncotic | Hyperoncotic: equivalent to about 5 times its volume of plasma | Albumin provides 70–80% of plasma colloid osmotic pressure |
| Na⁺ | 130–160 mEq/L (145 ± 15) | 130–160 mEq/L (145 ± 15) | Similar to plasma (135–145 mEq/L) |
| Stabilizers | Sodium caprylate and N-acetyltryptophan, 0.004 M each | Sodium caprylate and N-acetyltryptophan, 0.02 M each | Not present in plasma; hypersensitivity to them is a contraindication |
| Glucose (kcal) | None (0 kcal) | None (0 kcal) | — |
| pH | Adjusted to physiologic | Adjusted to physiologic | Physiologic |
| Clotting factors, preservative | None | None | Not a substitute for plasma or blood |
- 5% stays where you put it: plasma volume rises by about the volume infused.
- 25% recruits fluid: it pulls about 3.5 times its own volume out of the interstitium within about 15 min, if the patient is not markedly dehydrated. Example: 100 mL pulls in about 350 mL. In dehydration, use 5% or give crystalloid alongside.
- Sodium load: 25 g as 500 mL of 5% carries about 73 mEq of Na⁺. 25 g as 100 mL of 25% carries about 15 mEq.
- 20% products (10 g/50 mL, 20 g/100 mL) are hyperoncotic too. These values are for US products. Exact content varies by manufacturer.
Dosing & Administration
Doses vary by protocol; follow local protocols and medical direction.
Available Forms
- 5% (50 mg/mL): 12.5 g in 250 mL and 25 g in 500 mL bags or bottles
- 25% (250 mg/mL): 12.5 g in 50 mL and 25 g in 100 mL vials or bags
- 20% (200 mg/mL): 10 g in 50 mL and 20 g in 100 mL
- Single-dose and preservative-free. Most hospitals get it from the blood bank or pharmacy
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| Large-volume paracentesis (>5 L) | LVP: 6–8 g/L removed IV (grams per liter of ascites), as 20% or 25%, at the time of the tap (8 L removed: about 48–64 g) | Once per tap; max 2 g/kg/day | Taps under 5 L usually do not need albumin, but AASLD 2021 advises strongly considering it with systolic BP <90 mmHg, serum sodium <130 mmol/L or AKI. PPCD risk rises when more than 8 L is removed in one session |
| SBP (with antibiotics) | 1.5 g/kg IV on day 1, then 1 g/kg IV on day 3, as 20% or 25% | 2 doses only (days 1 and 3); max 2 g/kg/day | Greatest benefit with creatinine >1 mg/dL, BUN >30 mg/dL or bilirubin >5 mg/dL (AASLD 2021; ADQI/ICA 2024 and ICTMG 2024 cite bilirubin >4 mg/dL). ICTMG 2024: suggested to reduce mortality (Recommendation 11; conditional, low certainty); AGA 2024 best-practice advice: may be considered. Not for non-SBP infections |
| AKI in cirrhosis with suspected hypovolemia | 20–25% albumin IV, dose tailored to volume status. If volume status is unclear: fluid challenge of 1–1.5 g/kg of 20–25% albumin (or 250–500 mL crystalloid) per ADQI/ICA 2024. AASLD 2021 used 1 g/kg/day for 2 days | Reassess creatinine and urine output at 24 hr; max 2 g/kg/day (label) | Stop diuretics and nephrotoxins. ADQI/ICA 2024 no longer requires a fixed 2-day albumin challenge: no improvement within 24 hr of adequate volume resuscitation, with no strong alternative cause, supports HRS-AKI, so start the vasoconstrictor promptly. Do not load euvolemic or overloaded patients |
| HRS-AKI (with vasoconstrictor) | 20–25% albumin, commonly 20–40 g/day IV, adjusted daily to volume status (ADQI/ICA 2024). AASLD 2021: 1 g/kg on day 1, then 40–50 g/day | Continue with the vasoconstrictor, up to 14 days; reduce or stop for volume overload or pulmonary edema | AGA 2024: concurrent albumin can be considered, accounting for volume status. In the CONFIRM trial (TERLIVAZ label, section 14), 1 g/kg on day 1 (max 100 g), then 20–40 g/day, was the fluid challenge before enrollment; patients then received a median 50 g/day on treatment. Terlipressin 0.85 mg IV every 6 hr per label. Contraindicated with hypoxia (do not start if SpO₂ <90%), worsening respiratory symptoms, or ongoing coronary, peripheral or mesenteric ischemia; unlikely to benefit if SCr >5 mg/dL. Label: avoid in ACLF grade 3; with MELD ≥35 benefit may not outweigh risk. ICU alternative: norepinephrine |
| Hypovolemia or hypovolemic shock | 5%: 250–500 mL IV (12.5–25 g); or 25%: 100–200 mL IV (25–50 g) if the patient is well hydrated or edematous | Repeat after 15–30 min if response is inadequate; max 2 g/kg/day | Not first-line: crystalloid first, blood products for hemorrhage. Dose by volume status, not by serum albumin |
| Septic shock (adjunct) | Hypovolemia dosing above | Repeat after 15–30 min if response is inadequate; max 2 g/kg/day | Only after large crystalloid volumes or with cirrhosis, per SSC 2026. Avoid with traumatic brain injury |
| Burns ≥20% TBSA | No guideline dose; per burn-center protocol, titrated to urine output | Max 2 g/kg/day | ABA 2024: consider, especially in larger burns, to lower resuscitation volume and improve urine output. ICTMG 2024 suggests against albumin for volume replacement in thermal injury (Recommendation 2; conditional, very low certainty). Burn-center protocol only; never prehospital. Differs from FDA labels, which specify use after the first 24 hr |
| Therapeutic plasma exchange | 5% IV, volume matched to the plasma removed | Rate matched to removal rate; per apheresis protocol | Run by the apheresis service |
Dosing weight is the open question. AASLD sets no weight basis for g/kg doses, and ascites makes actual weight run high. Go by the weight your protocol specifies.
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Hypovolemic shock | 5%: 12–20 mL/kg IV (0.6–1 g/kg); or 25%: 2.5–5 mL/kg IV (0.6–1.25 g/kg) | Repeat after 15–30 min if response is inadequate; max 2 g/kg/day | Label dose for infants and young children; older children as adults. Not for initial sepsis resuscitation: use crystalloid (see Pediatric Shock) |
| Large-volume paracentesis | 25%: 0.5–1 g/kg IV, or 6–8 g per liter of ascites removed | Once per tap; max 2 g/kg/day | AASLD 2021; pediatric data are limited |
| SBP, AKI or HRS in cirrhosis | Not established in children | Not routinely used (consult) | Pediatric hepatology decides; terlipressin is labeled for adults only |
| Neonatal: hemolytic disease of the newborn | 25%: 1 g/kg IV before or during exchange transfusion | Single dose; max 2 g/kg/day | Neonatology only. Not suggested for volume replacement in preterm neonates (ICTMG Recommendation 6) |
Weight-based calculations: Pediatric Weight-Based Dosing.
Preparation & Administration
- Choose the concentration: 5% for volume deficits and dehydration. 20–25% when interstitial fluid is available (edema, ascites), or when added volume must be limited.
- Dilution: usually given undiluted. If you dilute it, use only 0.9% NaCl or D5W. Never Sterile Water for Injection.
- Rate: with normal blood volume, go no faster than 1 mL/min for 5% or 25% (FLEXBUMIN labels). Other labels vary, so check the product in hand. In shock, the hemodynamic response guides the rate. For children, KEDBUMIN labels a usual pediatric rate of one-fourth the adult rate. Other labels give no pediatric rate, so titrate to hemodynamic response per pediatric protocol.
- Inspect: clear to slightly opalescent, pale straw to amber or greenish. Do not use if turbid or if particles are present.
- Time limit: start within 4 hr of entering the container, and discard any remainder. There is no preservative. Some labels say to use the product within 4 hr of opening. Local policy may require the infusion to finish within 4 hr.
- Line: do not add drugs to the container and do not mix with blood components, protein hydrolysates or alcohol-containing solutions. Do not connect plastic containers in series (air embolism).
- Large volumes: warm to room temperature. Record the product name and lot number (plasma-derived product).
Dosing Notes:
- Work it in grams: 25 g is 500 mL of 5%, or 100 mL of 25%.
- Every indication has the same label maximum: 2 g/kg/day.
- Dose to circulating volume and the indication. Don't dose to a serum albumin target.
Contraindications & Precautions
Contraindications
- Hypersensitivity to albumin or to the stabilizers N-acetyltryptophan or sodium caprylate.
- Severe anemia or heart failure with normal or increased intravascular volume: acute pulmonary edema is the risk.
- Resuscitation in traumatic brain injury (TBI) (guideline, not label): avoid albumin. Use isotonic crystalloid, and blood as indicated, per trauma protocol. With sepsis and TBI, SSC 2026 suggests 0.9% saline over balanced crystalloids.
Precautions
- Overload or hemodilution risk: heart failure, hypertension, varices, pulmonary edema, bleeding disorders, severe anemia, renal failure.
- Trauma or postoperative: a rising BP can restart the bleeding.
- Large volumes: albumin carries no clotting factors, platelets or red cells. Replace them as indicated.
- With terlipressin: the boxed warning is fatal respiratory failure. The risk is higher with volume overload or grade 3 acute-on-chronic liver failure (ACLF), so cut albumin at the first sign of overload. The label says to avoid terlipressin in ACLF grade 3. With a high transplant priority (e.g., MELD ≥35), its benefit may not outweigh the risk that respiratory failure or ischemia makes the patient ineligible for transplant. Terlipressin is contraindicated with hypoxia or worsening respiratory symptoms, and with ongoing coronary, peripheral or mesenteric ischemia. Patients with SCr >5 mg/dL are unlikely to benefit.
- Plasma-derived: the risk of viral or Creutzfeldt-Jakob disease transmission is extremely remote. No case has been identified with licensed albumin.
Hold / Reassess If
- Overload signs: headache, dyspnea, jugular venous distension, crackles, rising BP or central venous pressure: stop.
- SpO₂ falling: stop. With terlipressin, stop terlipressin if SpO₂ <90%.
- Urticaria, wheeze or hypotension: stop. Treat as hypersensitivity.
- Hemoglobin falling: think hemodilution or bleeding. Transfuse as indicated.
Never dilute with Sterile Water for Injection: Fatal hemolysis and acute kidney failure can follow when 20–25% albumin is diluted in sterile water. Don't do it.
Adverse Effects & Toxicity
Common
- Flushing, urticaria, rash, pruritus
- Fever and chills
- Nausea, vomiting; headache; altered taste
- Tachycardia and hypotension. They usually settle when the rate slows or the infusion stops
- Frequencies are not established. The reports come from postmarketing use
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Circulatory overload, pulmonary edema | Dyspnea, crackles, jugular venous distension, falling SpO₂, rising BP; highest risk with rapid infusion, heart failure or renal failure | Stop the infusion; sit upright, oxygen and ventilatory support as needed; diuretic such as furosemide per protocol |
| Anaphylaxis | Hypotension, wheeze, urticaria or angioedema, usually early in the infusion | Stop; IM epinephrine and standard anaphylaxis care |
| Hemodilution and dilutional coagulopathy | Falling hemoglobin, oozing, abnormal coagulation tests after large volumes | Check CBC and coagulation tests; give red cells, plasma or platelets as indicated |
| Hemolysis and AKI from sterile-water dilution | Dark or red urine, falling hemoglobin, rising creatinine after a diluted dose | Stop; check how the dose was prepared; supportive care and nephrology input |
| Rebleeding | Trauma or postoperative patient whose BP rises, then falls; increasing drain output | Reassess the bleeding source; follow trauma BP targets; surgical review |
| Cardiac events | New atrial fibrillation, tachycardia, myocardial infarction (reported postmarketing) | ECG; slow or stop the infusion; treat the rhythm |
Overdose & Toxicity Management
- Signs: too much volume, or too fast. Watch for hypertension, dyspnea, pulmonary edema and falling hemoglobin.
- Immediate: stop the infusion, give oxygen and ventilatory support, and a loop diuretic per protocol (children: weight-based dosing).
- Antidote: there is none. Treatment is supportive.
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical: BP and heart rate | Before, every 5–15 min during a bolus, and after | Goal per indication (MAP 65 mmHg in septic shock; SSC 2026 suggests 60–65 mmHg for adults aged 65 or older). Trauma or postoperative BP spike: check for rebleeding |
| Clinical: lungs and oxygenation | Continuous SpO₂; lung sounds and work of breathing during and after each dose | Crackles, dyspnea or falling SpO₂: stop; treat pulmonary edema |
| Clinical: perfusion and urine output | Hourly in shock, burns and HRS; in shock, also lactate trend, mental status and capillary refill | Urine <0.5 mL/kg/hr in an adult or <1 mL/kg/hr in a child, rising lactate or worsening perfusion: reassess volume status and kidney function |
| Clinical: infusion reaction | First 15 min, then throughout | Flushing, urticaria, wheeze or hypotension: stop the infusion |
| Laboratory: hemoglobin and coagulation tests | After large volumes | Falling hemoglobin or abnormal coagulation: hemodilution or bleeding; replace blood components |
| Laboratory: creatinine and sodium | Daily in cirrhosis, SBP and HRS | HRS on terlipressin: creatinine down less than 30% by day 4 may increase dose; at or above baseline: stop terlipressin |
| Laboratory: serum albumin | Not a dosing target | Do not dose to correct a low value |
| Infusion safety: container time and lot | At spike and at handoff | Not started within 4 hr of entry: discard. Record product, concentration, grams and lot number |
| Infusion safety: paracentesis volume | During and after LVP | Tally liters removed to calculate grams (6–8 g/L); more than 8 L in one session raises PPCD risk |
Interactions & Compatibility
Clinically Significant Interactions
Labels list no pharmacokinetic drug interactions. In practice, the risks are the added volume and the drugs albumin gets paired with.
| Drug / Class | Effect | What To Do |
|---|---|---|
| Terlipressin (HRS-AKI) | Respiratory failure risk rises with volume overload from albumin and other fluids | Check SpO₂ before starting and continuously; reduce or stop albumin at the first sign of overload |
| Norepinephrine or midodrine with octreotide (HRS-AKI) | Vasoconstrictor plus albumin is the HRS treatment; midodrine with octreotide is much less effective | Pair with daily albumin; monitor volume status and ischemia |
| Loop diuretics (furosemide) | Albumin plus diuretic to remove edema in critically ill adults has no proven benefit | Do not give albumin just to boost diuresis; use diuretics alone or per protocol |
| ACE inhibitors (therapeutic plasma exchange with albumin replacement) | Atypical bradykinin-mediated reactions: flushing, hypotension, dyspnea, bradycardia | Apheresis services usually hold ACE inhibitors for at least 24 hr before the procedure; flag them at handoff |
| Other IV fluids and blood products | Additive volume; cumulative overload | Count all fluids in the balance; reassess before each bolus |
IV Compatibility
- Diluents: 0.9% NaCl or D5W only. Never Sterile Water for Injection.
- Do not mix in the container: other drugs, blood or blood components, protein hydrolysates or alcohol-containing solutions (protein precipitation).
- Co-administration: the labels differ. KEDBUMIN allows concomitant administration with whole blood, plasma, saline, glucose or sodium lactate when medically necessary, as long as nothing is mixed in. FLEXBUMIN and ALBUTEIN say only not to mix with other products. Read the label of the product in hand. Don't add supplementary medication.
- Verify with an institutional compatibility resource.
Special Populations
- Pediatrics: it is safe when dosed by weight. For children with sepsis or septic shock, SSC 2026 suggests crystalloids rather than albumin for initial resuscitation. ICTMG 2024 recommends against albumin to reduce mortality in children with infection and hypoperfusion (Recommendation 4). In the FEAST trial, both albumin and saline boluses raised mortality compared with no bolus. See the Pediatric Dosing table.
- Neonates: it goes in before exchange transfusion for hemolytic disease of the newborn. The guidelines do not suggest it for volume replacement in preterm neonates (≤32 weeks or ≤1,500 g), or to improve breathing in preterm infants with low albumin (ICTMG Recommendations 5 and 6).
- Pregnancy: the FLEXBUMIN label (section 8.1) has no human or animal data on drug-associated risk. Albumin is a normal plasma protein. Give it when clearly indicated (e.g., volume deficit, severe ovarian hyperstimulation syndrome).
- Lactation: there are no human or animal data (FLEXBUMIN label, section 8.2). It is unknown whether infused albumin enters breast milk. Weigh the benefits of breastfeeding against the mother's need for albumin.
- Older Adults: there are no specific data. Heart failure and reduced reserve raise overload risk. Use smaller volumes and reassess often.
- Renal Impairment: no dose adjustment is established, and renal failure raises overload risk. The guidelines do not suggest it for intradialytic hypotension or to improve ultrafiltration (ICTMG Recommendation 7).
- Hepatic Impairment: cirrhosis is where the evidence for benefit is strongest (LVP, SBP, HRS). Not for uncomplicated ascites (ICTMG Recommendation 14). Not for infections other than SBP (Recommendation 12). Not to raise albumin above 30 g/L in hospitalized decompensated cirrhosis. Recommendation 13 found no benefit on infection, kidney dysfunction or death, and more serious adverse events, mainly a numerical increase in pulmonary edema.
- Obesity / Dosing Weight: guidelines give no weight basis for g/kg albumin doses. Ascites and edema inflate actual weight. Use the weight your protocol specifies, and respect the 2 g/kg/day label maximum.
- Traumatic Brain Injury: avoid albumin for resuscitation. Isotonic crystalloid and blood go in as indicated, per trauma protocol. With sepsis and TBI, SSC 2026 suggests 0.9% saline rather than a balanced crystalloid.
Field & Transport Considerations
- Scope: RN and critical-care transport (CCT) teams usually run it on interfacility transfers, or for a patient after paracentesis. Ground EMS rarely carries it. Varies by state and agency protocol.
- Storage & Stability: room temperature, not above 25°C (77°F) or 30°C (86°F), depending on the product. Do not freeze it. Keep it out of hot vehicle compartments. Once spiked, start within 4 hr and discard the remainder. Follow local policy if it requires finishing within 4 hr.
- Carried Concentration: 5% and 25% look alike and share a name. Confirm the percentage and grams on the label. Giving 25% as a 5% volume bolus causes overload. Giving 5% for an ascites dose adds 5 times the fluid.
- Infusions in Transport: run it on a pump, with no other drugs in the line. Do not connect plastic containers in series. Reassess lungs and SpO₂ after each move and at altitude.
- Handoff Essentials: indication, concentration, grams given and remaining, container entry and start times (4-hr limit), liters of ascites removed, vitals and SpO₂ trend, terlipressin or norepinephrine doses and times, and any reaction.
Clinical Pearls
Order in grams: 25 g is 500 mL of 5%, or 100 mL of 25%. The oncotic dose is identical. But 25% brings about one-fifth of the water and sodium. That is why liver patients get 20–25%.
Head injury: in traumatic brain injury, albumin resuscitation was associated with higher mortality than saline. Hypotensive head injury gets isotonic crystalloid and blood per trauma protocol. Not albumin. With sepsis and TBI, SSC 2026 suggests 0.9% saline over balanced crystalloids.
Sepsis 2026 update: SSC 2026 now suggests crystalloids alone, not crystalloids plus albumin. Albumin remains reasonable after large crystalloid volumes, or in cirrhosis. Balanced crystalloid is still the default. Traumatic brain injury is the one exception that gets 0.9% saline.
5% vs 25% vs crystalloid:
- 5% albumin: iso-oncotic. It expands plasma by about the volume given
- 25% albumin: hyperoncotic. It pulls about 3.5 times its volume in from the tissues, so it needs interstitial water to work
- Balanced crystalloid: first-line. Most of the volume leaves the vessels, but it is cheap and effective
- Crystalloid vs albumin in ICU trials: mortality does not differ
Exam discriminator (CCRN, CFRN, FP-C): With cirrhosis and SBP, you give antibiotics and albumin, since albumin prevents kidney failure. With cirrhosis and pneumonia or a urinary infection, give antibiotics alone. Albumin adds pulmonary edema without benefit.
Treat the patient, not the number: a low serum albumin is not a dosing target (FLEXBUMIN label, section 2.1). Giving albumin to reach a target gave no benefit in decompensated cirrhosis. Pulmonary edema was numerically higher (ICTMG Recommendation 13). In ICU patients, there is no proven benefit (Recommendation 1).
Terlipressin plus albumin, watch the lungs: terlipressin's boxed warning is respiratory failure, and the main risk factor is volume overload. Check SpO₂ before you start and keep watching it. At the first crackle, cut back albumin.
Pharmacology
Mechanism of Action
- Oncotic pressure: albumin supplies 70–80% of plasma colloid osmotic pressure. That holds water in the vessels, and circulating volume expands.
- 5% vs 25%: 5% is about iso-oncotic, so the volume in equals the volume gained. 25% is equivalent to about 5 times its volume of plasma, and it recruits interstitial fluid within about 15 min.
- Effective arterial volume in cirrhosis: after paracentesis and in SBP, albumin restores central volume. That protects kidney perfusion.
- Transport protein: albumin binds drugs, hormones, bilirubin and toxins. That binding is the basis for its use in hemolytic disease of the newborn.
Pharmacokinetics
| Route | Onset | Peak | Duration |
|---|---|---|---|
| IV, 5% | Immediate | End of infusion | Hours; longer in hypovolemia, shorter with normal volume or capillary leak |
| IV, 25% | Immediate | About 15 min (fluid recruitment) | Hours; shorter with capillary leak (sepsis, burns) |
- Half-life: albumin itself has a half-life of 15–20 days, with turnover about 15 g/day (FLEXBUMIN 25% label, section 12.3). The volume effect is far shorter, and it depends on capillary leak.
- Distribution: a 70-kg adult has about 350 g of total body albumin, and more than 60% of it sits outside the vessels (FLEXBUMIN 25% label, section 12.3). Critical illness speeds the leak into the tissues.
- Metabolism: it is broken down inside cells by lysosomal proteases. CYP enzymes are not involved.
- Active metabolites: none.
Names & Classification
- Generic Name
- Albumin (Human), USP; 5%, 20% and 25% solutions
- Brand Names
- Albutein, AlbuRx, Albuked, Albuminex, Flexbumin, Kedbumin, Plasbumin, Human Albumin Grifols; unbranded Albumin (Human)
- Pharmacologic Class
- Plasma-derived protein; natural colloid
- Therapeutic Class
- Plasma volume expander
- Controlled Substance
- Not controlled
- ISMP High-Alert
- No
- Look-Alike / Sound-Alike
- None commonly reported; the practical mix-up is 5% vs 25% (or 20%) of the same product. Confirm percentage and grams
References
- U.S. National Library of Medicine, DailyMed. (2026). Albumin (Human) prescribing information: FLEXBUMIN 25% and FLEXBUMIN 5% (Takeda, rev. 12/2024); KEDBUMIN 25% (Kedrion, rev. 6/2025); ALBUTEIN FlexBag 5% (Grifols, rev. 3/2025). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bdb4e167-27a2-4b50-b245-43df9cd535cb; https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=79094f4e-5f5c-44d6-b563-d6078eafe83a; https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=57bd6811-8619-11e0-9d78-0800200c9a66; https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a6ca2871-9a9d-4f03-a5ff-ddb28c6ff945
- Mallinckrodt Hospital Products. (2026). TERLIVAZ (terlipressin) for injection: prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3a35b86c-f451-4fac-8499-43019e4da354
- Surviving Sepsis Campaign 2026 guidelines, adult and pediatric. Prescott, H. C., Antonelli, M., Alhazzani, W., Møller, M. H., et al. (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine, 54(4), 725–812. https://doi.org/10.1097/CCM.0000000000007075; Weiss, S. L., Peters, M. J., Oczkowski, S. J. W., Belley-Cote, E., et al. (2026). Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatric Critical Care Medicine, 27(4), 379–434. https://doi.org/10.1097/PCC.0000000000003927
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- Garcia-Tsao, G., Abraldes, J. G., Rich, N. E., & Wong, V. W. (2024). AGA clinical practice update on the use of vasoactive drugs and intravenous albumin in cirrhosis: Expert review. Gastroenterology, 166(1), 202–210. https://doi.org/10.1053/j.gastro.2023.10.016
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