Albumin 20%

notes on albumin IV infusion for clinical pharmacists in intensive care units

1. Albumin (human) 20% solution Dr. Dalia K. Zaafar Lecturer of Clinical Pharmacology

2. What is albumin Albumin is an important factor in regulation of plasma volume and tissue fluid balance through its contribution to the colloid oncotic pressure of plasma Albumin is a highly soluble globular protein with a relatively low molecular weight (66,500) and exerts 70–80% of the colloid oncotic pressure of normal plasma IV administration of concentrated albumin human solution causes a shift of fluid from the interstitial spaces into the circulation and a slight increase in the concentration of plasma proteins

3. What is albumin When used for treatment of hypovolemia, most effective in well-hydrated patients. Not considered and not used as an IV nutrition source. Binds and functions as a carrier of intermediate metabolites (including bilirubin), trace metals, some drugs, dyes, fatty acids, hormones, and enzymes, thus affecting the transport, inactivation, and/or exchange of tissue products

4. What is albumin human 20% A protein colloid; a sterile solution of serum albumin prepared by fractionating pooled plasma from healthy human donors It is a 20% sterile solution of albumin in an aqueous diluent. Stabilized with 0.02 M sodium caprylate and 0.02 M acetyl tryptophan and buffered with sodium carbonate.

5. What is albumin human 20% The approximate sodium content of the product is 145 meq/L. Must be administered intravenously. Made from pooled human venous plasma using the Cohn cold ethanol fractionation process.

6. INDICATIONS AND CLINICAL USE The oncotic and colloid properties of albumin solution are used to restore and maintain circulating blood volume, when needed The choice of albumin over other colloid or crystalloid solutions will depend on the clinical situation of the individual patient, according to current therapeutic guidelines and recommendations.

7. INDICATIONS AND CLINICAL USE 1- Emergency treatment of hypovolemic shock Albumin 20% is hyper oncotic and on intravenous infusion will expand the plasma volume by an additional three to four times the volume actually administered, by withdrawal of fluid from the interstitial spaces, in case of normally interstitially hydrated patient, or in case of interstitial edema, while for dehydrated patients an additional crystalloids must be given, or monitor hemodynamic response to prevent circulatory overload

8. INDICATIONS AND CLINICAL USE 1- Emergency treatment of hypovolemic shock The total dose should not exceed the normal level of albumin (about 2 g/kg). Albumin (Human) 5% is be preferred for the usual volume deficits Albumin 20% with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed

9. INDICATIONS AND CLINICAL USE 1- Emergency treatment of hypovolemic shock Albumin human should not be considered a substitute for blood or blood components when oxygen-carrying capacity is reduced and/or when replenishment of clotting factors or platelets is necessary. Transfusion with whole blood or packed RBCs is required in patients with active hemorrhage or substantial anemia

10. INDICATIONS AND CLINICAL USE 1- Emergency treatment of hypovolemic shock Theoretical advantages of colloids include greater retention in the intravascular space, more effective and rapid plasma volume expansion, and reduced risk of pulmonary edema. Colloids generally have not been shown to be more effective than crystalloids, and costs associated with colloids are substantially higher than those associated with crystalloids.

11. INDICATIONS AND CLINICAL USE 1- Emergency treatment of hypovolemic shock Based on current evidence, albumin human appears to offer no survival advantage over crystalloids for fluid resuscitation

12. INDICATIONS AND CLINICAL USE 2- Neonatal hemolytic disease It may be indicated to administer albumin 20% prior to exchange transfusion, in order to bind free bilirubin, in order to lessen the risk of kernicterus. A dosage of 1 g/kg body weight is given about 1 hour prior to exchange transfusion. Caution must be observed in hypervolemic infants

13. INDICATIONS AND CLINICAL USE 3- Acute liver failure In rapid loss of liver function, administration of albumin may serve in supporting the colloid osmotic pressure of the plasma and binding excess plasma bilirubin

14. INDICATIONS AND CLINICAL USE 4- Acute nephrosis & nephrotic syndrome Used as an adjunct to diuretic therapy to treat edema in patients with acute nephrosis refractory to cyclophosphamide and steroid therapy. Cardinal features of nephrotic syndrome include albuminuria, hypoalbuminemia, and edema. Decreased hepatic production and increased renal catabolism are responsible for hypoalbuminemia and renal sodium retention is responsible for edema.

15. INDICATIONS AND CLINICAL USE 4- Acute nephrosis & nephrotic syndrome Principal goal of therapy is treating the underlying cause. Diuretic therapy is treatment of choice for symptomatic management. UHC guidelines recommend short-term adjunctive use of albumin human with diuretics in adults with nephrotic syndrome who have acute, severe peripheral and/or pulmonary edema unresponsive to diuretics alone.

16. INDICATIONS AND CLINICAL USE 5- Adult respiratory distress syndrome It is characterized by deficient oxygenation caused by pulmonary interstitial edema. Albumin 20% with diuretics play together a role in therapy when clinical signs of hypoproteinemia and fluid volume overload exist.

17. Contraindications should not be given to patients who are hypersensitive to albumin or to any ingredient in the formulation or component of the container. should not be given to patients at special risk of developing circulatory overload like patients with a history of congestive cardiac failure, renal insufficiency or stabilized chronic anemia

18. When is albumin administration not warranted?? 1- In chronic nephrosis, infused albumin is promptly excreted by the kidneys with no relief of the chronic edema or effect on the underlying renal lesion. 2- undernutrition as albumin infusion is not justified to be used as a source of protein nutrition

19. Precautions 1- Albumin solution must not be diluted with sterile water for injection as this may cause hemolysis and acute renal failure in recipient. 2- Use immediately after vial or container is opened, and discard if >4 hours have elapsed since container was first entered. 3- albumin solution may contain more than 200 μg/L of aluminum. It shouldn’t be used to treat infants or patients on hemodialysis. 4- A rapid rise in blood pressure may follow the administration of a colloid with positive oncotic activity necessitates careful observation

20. Special populations 1- Pregnant Woman Category C: consider potential risks and benefits for the specific patient 2- Nursing Women It is not known whether it can cause harm to the fetus or nursing child. It should be given to a pregnant or nursing woman only if the benefit outweighs any potential risk. 3- Pediatrics safety has been demonstrated in children receiving dosage appropriate for body weight Albumin isn’t preferred to be used in neonates and infants

21. Specific drug interaction ACE Inhibitors Increased risk of atypical reactions (flushing, hypotension) to ACE inhibitors in patients undergoing therapeutic plasma exchange with albumin human replacement So it is recommended to withhold ACE inhibitors for 24 hours prior to albumin human administration

22. Compatibility Can be administered in conjunction with whole blood or plasma, or with dextrose, sodium lactate, or sodium chloride injections. Can’t be mixed with parenteral nutrient solutions, protein hydrolysates, amino acid solutions, or solutions containing alcohol as proteins may precipitate in the solutions.

23. Doses & dose adjustment The infusion rate must be adjusted to individual requirements, based on initial assessment and monitoring of the patient’s status. It should normally not exceed 1 to 2 mL/minute. The volume administered and the speed of infusion should be adapted to the response of the individual patient.

24. Overdosage To date, there have been no reported cases of overdose Albumin 20% is hyper-oncotic, so patients should be monitored against the possibility of circulatory overload. In such case, provide standard supportive treatment as necessary. Hypervolemia may occur if the dosage and rate of infusion are too high. If hypervolemia is suspected, stop the infusion immediately and carefully monitor the patient’s hemodynamic parameters

25. Thank You!