1 Albumin - Adult - Inpatient Clinical Practice Guideline Note: Active Table of Contents – Click to follow link EXECUTIVE SUMMARY ........................................................................................................................................... 3 SCOPE .................................................................................................................................................................... 4 METHODOLOGY ..................................................................................................................................................... 4 DEFINITIONS .......................................................................................................................................................... 5 INTRODUCTION ..................................................................................................................................................... 5 RECOMMENDATIONS ............................................................................................................................................ 6 UW HEALTH IMPLEMENTATION ........................................................................................................................... 10 APPENDIX A. EVIDENCE GRADING SCHEME(S) ..................................................................................................... 11 REFERENCES ......................................................................................................................................................... 12 Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 2 Contact for Content: Name: Philip Trapskin, PharmD - Pharmacy Phone Number: (608) 263-1328 Email Address: ptrapskin@uwhealth.org Contact for Changes: Name: Philip Trapskin, PharmD - Pharmacy Phone Number: (608) 263-1328 Email Address: ptrapskin@uwhealth.org Guideline Authors: Jeff Fish, PharmD - Pharmacy Coordinating Team Members: Joshua Vanderloo, PharmD - Pharmacy Review Individuals/Bodies: Gauri Bhutani, MD - Nephrology Aimee Becker, MD - Anesthesiology Bartho Caponi, MD - Hospital Medicine Anthony D’Alessandro, MD - Transplant Surgery Arjang Djamali, MD - Nephrology Lee Faucher, MD - Trauma Surgery David Foley, MD - Transplant Surgery Hee Soo Jung, MD - Trauma Surgery Dixon Kaufman, MD - Transplant Surgery Jonathan Ketzler, MD - Anesthesiology James Maloney, MD - Cardiothoracic Surgery Didier Mandelbrot, MD - Nephrology Josh Medow, MD - Neurosurgery Jon Odorico, MD - Transplant Surgery Ann O’Rourke, MD - Trauma Surgery Marie Pietruszka, PharmD - Pharmacy John Rice, MD - Gastroenterology Tripti Singh, MD - Nephrology Philip Trapskin, PharmD - Pharmacy Jeffery Wells, MD - Pulmonary Medicine David Yang, MD - Clinical Laboratory Committee Approvals/Dates: Pharmacy & Therapeutics Committee June 2022 Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 3 Executive Summary Guideline Overview This guideline provides recommendations for the therapeutic use of albumin to treat several common disorders in the inpatient setting. Individual clinician experience may suggest stronger recommendations for some indications. However evidence based conclusions are derived from the currently available evidence. Key Practice Recommendations 1. Albumin is recommended for the diagnosis and treatment of Type 1 hepatorenal syndrome with cirrhosis 2. Albumin is recommended for the treatment of spontaneous bacterial peritonitis with cirrhosis in conjunction with appropriate antimicrobial therapy 3. Repletion with albumin is recommended after large volume paracentesis in cirrhosis and after plasmapheresis 4. General use of albumin to treat all patients with sepsis is not recommended, however albumin may be considered for the treatment of septic and hemorrhagic shock following failure of isotonic crystalloid fluids 5. Albumin may be considered in patients that are edematous but intravascularly depleted and with a plasma albumin <2 g/dL. Examples populations include patients with cirrhosis that have ascites that is unresponsive to diuretics and who are not undergoing paracentesis OR patients who have undergone major surgery (e.g. > 40% hepatic resection or extensive intestinal resection) 6. Use of albumin may be considered to treat burns when appropriate administration of crystalloid fluid does not result in minimum urine output. 7. Albumin may be considered to treat volume depletion following liver transplant 8. Albumin may be considered for treatment of hypo-oncotic shock in patients with acute respiratory distress syndrome 9. Albumin may be considered to treat diuretic resistance 10. Albumin may be considered to treat symptomatic hypotension during hemodialysis 11. Albumin should not be administered to patients with traumatic brain injury and should be administered with care in the setting of other traumas Companion Documents 1. Sepsis: Diagnosis and Management - Adult - Inpatient/Emergency Department 2. Parenteral Nutrition - Adult - Inpatient/Ambulatory Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 4 Scope Diseases/Conditions: Cirrhosis, hepatorenal syndrome, spontaneous bacterial peritonitis, extracorporeal membrane oxygenation, septic shock, hemorrhagic shock, burns, volume depletion/ expansion, cardiac surgery, liver transplantation, nephrotic syndrome, acute lung injury/ acute respiratory distress syndrome, hemodialysis Clinical Specialty: The following clinical specialties may use this guideline: Critical Care, Hospital Medicine, Pulmonology, Surgery, Transplantation, Hepatology, Nephrology, Cardiology, Trauma, Infectious Disease, Anesthesia, and Nutrition Support Intended Users: Physicians, Advanced Practice Providers, Nurses, Nutrition Support, Pharmacists, Technical Support Objective: To provide evidence-based recommendations to assist clinicians in determining the benefits of albumin use in patients with relevant disorders Target Population: All adult inpatients cared for within UW Health who have a disorder for which albumin may be appropriate treatment Interventions and Practices Considered: Albumin is the sole clinical intervention considered in the guideline, sometimes as a second or third line therapy Major Outcomes Considered: • Mortality • Blood pressure • Fluid balance • Plasma albumin level Methodology Methods Used to Collect/Select the Evidence: Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and workgroup members to collect evidence for review. Expert opinion and clinical experience were also considered during discussions of the evidence. Methods Used to Formulate the Recommendations: The workgroup members agreed to adopt recommendations developed by external organizations and/or arrived at a consensus through discussion of the literature and expert experience. All recommendations endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or committees (as appropriate). Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations: Recommendations developed by external organizations maintained the evidence grade assigned within the original source document and were adopted for use at UW Health. Internally developed recommendations, or those adopted from external sources without an assigned evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1 in Appendix A). Rating Scheme for the Strength of the Evidence/Recommendations: See Appendix A for the rating scheme(s) used within this document. Cost Analysis: No formal cost analysis was done to direct the recommendations made in this guideline Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 5 Recognition of Potential Health Care Disparities: Insofar as care for the disorders described above is initiated, there are no recognized health care disparities when administering albumin. Definitions Extracorporeal membrane oxygenation: a modified form of cardiopulmonary bypass to support both cardiac and pulmonary function Diuretic resistance: An inadequate response to typically effective doses of loop diuretics despite clear presence of hypervolemia including inadequate diuresis, worsening of renal function or development of hypotension Cirrhosis: a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules Hepatorenal syndrome: functional renal failure associated with advances cirrhosis. The diagnosis includes cirrhosis and ascites plus impaired renal function after exclusion of parenchymal renal disease Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection Spontaneous bacterial peritonitis: an ascitic fluid infection without an evident intra-abdominal surgically treatable source. Introduction Albumin is a protein-based colloid therapy used in fluid resuscitation for hypovolemic states associated with various conditions and for correcting hypoalbuminemia in circumstances of specific symptomatology. The major indication for use of albumin therapy is volume expansion. Other classes of agents used to manage hypovolemic states include crystalloid fluids. Albumin is substantially more expensive than crystalloid fluids. A Cochrane review evaluated 74 randomized controlled trials comparing the use of colloid to crystalloid therapy for volume replacement in critically ill patients and found no evidence of decreased mortality with colloid use over crystalloids.1 Meanwhile, a prospective cohort study in a surgical ICU demonstrated that implementing albumin use guidelines decreased albumin use by 54%.2 The restrictive use of albumin had no negative impact on ICU mortality, but resulted in a 56% reduction in cost. This demonstrates that evidence based recommendations organized in guidelines endorsed by stakeholders can increase the probability of deriving optimal value from albumin. General guidelines for the use of albumin are available in the published literature3-6 and were consulted in the creation of this guideline. The recommendations established in this guideline reflect current evidence and local expert opinion. Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 6 Recommendations Albumin administration is recommended for the following indications 1. Management of hepatorenal syndrome (HRS) or acute kidney injury (AKI) in patients with cirrhosis and probable non-structural injury (i.e. pre-renal azotemia) a. Establish differential diagnosis7, 8 i. Use of albumin as fluid challenge is recommended (UW Health low quality evidence; strong recommendation) 1. When patient is clinically volume depleted a. Albumin type: 5% b. Dose until clinical volume repletion is achieved; suggested initial dose is 12.5 g to 25 g (250-500 mL) 2. When there is no evidence of obvious volume depletion a. Albumin type: 25% b. Dose: 1 g/kg per day for 2 days, maximum daily dose: 100 g (400 mL) ii. Assess for resolution or progression of AKI at 48 hours after initiating albumin therapy b. Treatment of Type 1 HRS with albumin in patients with cirrhosis is recommended3, 5, 6, 9-11 (UW Health high quality evidence; strong recommendation) i. Albumin type: 25% ii. Dose: 1 g/kg on day 1, maximum daily dose: 100 g (400 mL) iii. Suggested subsequent daily dose is 25 g/day (100 mL) iv. Must be given in combination with octreotide and midodrine with a goal to increase mean arterial pressure by at least 15 mmHg from baseline6 1. Octreotide dose: Initially, 100 mcg subcutaneously 3 times daily; titrate to 200 mcg subcutaneously 3 times daily 2. Midodrine dose: Initially 5-10 mg orally 3 times daily; titrate to 12.5 mg orally 3 times daily v. Alternatively a norepinephrine infusion, titrated to appropriate dose, may be used for vasoconstriction in combination with albumin if the patient resides in an intensive care unit. vi. The following duration of therapy for albumin is recommended3 1. In patients that respond to vasoconstrictors and albumin as evidenced by a decrease in creatinine, discontinue albumin when creatinine has returned to or is close to baseline, or has not decreased further after 3 days of treatment 2. In patients that do not respond to vasoconstrictors and albumin, discontinue albumin after a maximum of 7 days 3. Discontinue albumin if patient is started on renal replacement therapy or the plasma albumin concentration is >3 g/dL 2. Treatment of spontaneous bacterial peritonitis (SBP) with albumin in patients with cirrhosis is recommended3, 10, 12, 13 (UW Health moderate quality evidence; strong recommendation) a. Albumin type: 25% b. Dose: 1.5 g/kg on day 1, followed by 1 g/kg on day 3, Maximum daily dose: 100 g (400 mL) c. Albumin should be given with appropriate antibiotics 3. For large volume serial paracentesis (>5 L) in patients with ascites due to cirrhosis and without infection, an albumin infusion of 6 g to 8 g per liter of ascitic fluid removed is recommended to decrease the risk of post-paracentesis circulatory dysfunction and to improve survival.3, 6, 14-17 (UW Health moderate quality evidence; weak/conditional recommendation) a. Albumin type: 25% b. Dose: Albumin dose is determined by the volume of ascitic fluid removed (approximately 6 to 8 g per liter of fluid removed)6 c. Routine replacement of albumin is not recommended if 0-4.9 L are removed. The instructions of the ordering provider should be followed to determine the need for albumin based on patient comorbidities such as renal dysfunction, small body habitus, severe hypoalbuminemia or symptomatic hypotension following paracentesis. d. Maximum dose: 100 g (400 mL) Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 7 Paracentesis Volume Removed Albumin Dose (grams) 0-4.9 L Follow instructions of ordering provider to determine need for albumin 5-6.9 L 37.5 g 7-8.9 L 50 g 9-10.9 L 62.5 g 11-12.9 L 75 g 13-14.9 L 87.5 g ≥15 L 100 g 4. Volume repletion with albumin following therapeutic large-volume plasmapheresis is recommended when the following criteria are met5, 18 (UW Health low quality evidence; strong recommendation) a. More than 20 mL/kg in a single session or more than 20 mL/kg/week in successive sessions b. Albumin type: 5% c. Dose: replace 70-80% of plasma volume removed with albumin Albumin administration may be considered for the following indications 1. Treatment of shock states with albumin may be considered after failure of crystalloids to restore adequate fluid volume19-26 (UW Health moderate quality evidence; weak/conditional recommendation) a. Septic shock i. Crystalloids are recommended as the initial fluid of choice in the resuscitation of septic shock26 (UW Health moderate quality evidence; strong recommendation) ii. Albumin (5%) may be considered for resuscitation in specific patients with septic shock that require substantial fluid support in addition to crystalloids to maintain adequate mean arterial pressure. However, given the high cost of albumin compared to crystalloid fluid, routine administration of albumin is not recommended in the setting of septic shock.26 (UW Health low quality evidence; weak/conditional recommendation) 1. Albumin type: 5% 2. Dose: 12.5 g (250 mL), repeat as needed b. Hemorrhagic shock1, 27 (UW Health moderate quality evidence; weak/conditional recommendation) i. Albumin may be considered as last line therapy after crystalloids and blood products have been used at maximal doses without adequate clinical response. Albumin administration is contraindicated in patient with traumatic brain injury and should be used with care in patients with traumatic injuries. 1. Albumin type: 5% 2. Dose: 12.5 g (250 mL) is suggested, repeat as needed 2. Treatment with albumin may be considered in patients who are edematous but intravascularly depleted and who have a plasma albumin <2 g/dL.3, 6, 28-34 (UW Health moderate quality evidence; weak/conditional recommendation). Example populations include: a. Patients with cirrhosis and ascites which is unresponsive to diuretics but who are not undergoing paracentesis b. Patients who have undergone major surgery (e.g. >40% hepatic resection, extensive intestinal resection) c. Albumin type: 25% d. Dose: 12.5-25 g (50-100 mL), repeat as needed 3. Treatment with albumin may be considered in patients who have cirrhosis without ascites who have a plasma albumin <3 g/dL. The utility of giving albumin in patients with cirrhosis without ascites with serum albumin >3 g/dL is minimal and is not recommended.35, 36 (UW Health moderate quality evidence; weak/conditional recommendation). a. Albumin type: 25% b. Dose: 12.5 g to 25 g (50-100 mL), repeat as needed Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 8 4. Albumin may be considered for the treatment of burns when the projected 24-hour crystalloid fluid requirement to achieve urine output of >0.5 mL/kg/hr exceeds twice the volume calculated by the Parkland formula1, 5, 37-40 (UW Health low quality evidence; weak/conditional recommendation) a. Albumin type: 25% b. Dose: Initiate albumin at a rate of 10 mL/hr until crystalloid fluid requirements for adequate urine output (>0.5 mL/kg/hr) return to the volume calculated by the Parkland formula (2-4 mL/kg/% Total Burn Surface Area) 5. Treatment of volume depletion due to cardiothoracic and vascular surgery with albumin may be considered5, 41, 42 (UW Health low quality evidence; weak/conditional recommendation) a. For volume expansion during cardiac surgery (in addition to crystalloids) i. Albumin type: 5% ii. Dose: 12.5 g to 25 g (250-500 mL) b. For volume expansion following cardiac surgery (in addition to crystalloids) i. Albumin type: 5% ii. Dose: 12.5 g (250 mL) is suggested, repeat as needed c. For priming of the extracorporeal cardiopulmonary bypass circuit42 i. Albumin type: 25% ii. Dose: 12.5 g to 25 g (50-100mL) d. For volume expansion necessary when there is large blood loss as a result of abdominal aortic aneurysm (AAA) or thoracic aortic aneurysm (TAA) repair i. Albumin type: 5% ii. Dose: 12.5 g (250 mL) is suggested, repeat as needed 6. Treatment of volume depletion due to liver transplantation with albumin may be considered43, 44 (UW Health low quality evidence/ weak conditional recommendation) a. Albumin administration is appropriate when plasma albumin is <2.5 g/dL and patient is determined to be fluid responsive i. For postoperative control of ascites and peripheral edema 1. Albumin type: 25% 2. Dose: 12.5 g to 25 g (50-100 mL) is suggested: repeat as needed ii. To replace large volumes of ascitic fluid through drainage tubes 1. Albumin type: 5% 2. Dose: 12.5 g to 25 g (250-500 mL) is suggested; repeat as needed 3. Consider stopping albumin when drain output is <500 mL/day 7. Prevention of edema and graft reperfusion injury during and immediately following pancreas transplant with albumin may be considered for solitary pancreas and simultaneous pancreas/kidney transplants (UW Health very low quality evidence; weak/conditional recommendation) a. Albumin type: 25% b. Dose: 12.5 g to 25 g (50-100 mL) is suggested, repeat as needed 8. Albumin may be considered for the treatment of diuretic resistance in the setting of total body hypervolemia with intravascular depletion or low effective circulating volume and serum albumin <2.5 g/dL. Administration of albumin for diuretic resistance should be discontinued when serum albumin >3 g/dL or if negative fluid balance is not achieved within 24 hours of use if hypertension develops. Routine use of albumin for diuretic resistance in patients not meeting these criteria is not recommended.33, 45-47 (UW Health low quality evidence; weak/conditional recommendation) a. Albumin should be used in conjunction with diuretics b. Albumin type: 25% c. Dose: 12.5 g to 25 g (50-100 mL) is suggested up to twice per day 9. Albumin may be considered for the treatment of acute lung injury or acute respiratory distress syndrome48-50 (UW Health moderate quality evidence; weak/conditional recommendation) Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 9 a. Albumin administration is appropriate when the total plasma protein, level is less than 6 g/dL (note the distinction between total plasma protein and albumin; the plasma albumin level is not used as criteria for albumin administration in these disorders) b. Albumin should be used in conjunction with furosemide i. Albumin type: 25% ii. Dose: 25 g (100 mL) every 8 hours as needed for 3 days iii. Discontinue when total plasma protein level is greater than 8 g/dL 10. Albumin may be considered for the treatment of symptomatic hypotension during hemodialysis51, 52 (UW Health moderate quality evidence; weak/conditional recommendation) a. Albumin administration is appropriate as second line volume expansion after crystalloid administration i. Albumin type: 25% ii. Dose: 12.5 g to 25 g (50-100 mL) every 15 minutes as needed to keep systolic blood pressure (SBP) above 90 mmHg 11. Albumin may be considered to increase the extracorporeal membrane oxygenation (ECMO) flow rate when the rate is less than 10% of ordered flow for at least 5 minutes (UW Health very low quality evidence; weak recommendation). a. Albumin type: 25% b. Dose: 12.5 g to 25 g (50-100 mL) for each administration 12. Albumin administration may be considered in non-traumatic neurosurgery patients when use of crystalloid solutions may result in adverse effects. This includes albumin administration in the operating room and the endovascular/hybrid suite to manage volume depletion resulting from diuretic use or to prevent or treat vasospasm (UW Health very low quality evidence; weak/conditional recommendation) a. Albumin type: 5% b. Dose: 12.5 g to 25 g (250-500 mL), repeat as necessary 13. Albumin may be considered for sustaining organ function in brain dead patients while awaiting organ procurement when crystalloid fluid or pressor administration fails to maintain mean arterial pressure above 70 mmHg and the plasma albumin is less than 2 g/dL53 (UW Health low quality evidence; weak/conditional recommendation) a. Albumin type: 25% b. Dose: 12.5 g to 25 g (50-100 mL) Albumin is harmful and is contraindicated for the following indications 1. Fluid resuscitation in patients with traumatic brain injury.54 A post-hoc, subgroup analysis of fluid resuscitation among critically ill patients with traumatic brain injury revealed a higher mortality rate when albumin was administered as compared to saline. The subgroup was identified from all critically ill subjects studied in the Saline versus Albumin Fluid Evaluation Study.21 (UW Health low quality evidence; strong recommendation) Albumin administration is not recommended for the following indications as available evidence is insufficient to support use 1. To correct plasma albumin in patients not described above with plasma albumin >2.5 g/dL55-57 (UW Health low quality evidence; weak/conditional recommendation) 2. To treat sepsis without shock19, 24 (UW Health moderate quality evidence; weak/conditional recommendation) 3. To treat malnutrition, protein losing enteropathies, or malabsorption58, 59 (UW Health very low quality evidence; weak/conditional recommendation) 4. As fluid resuscitation in patients with acute trauma21, 57 (UW Health moderate quality evidence; weak/conditional recommendation) 5. Treatment of hepatic encephalopathy in patients with cirrhosis60 (UW Health low quality evidence; weak/conditional recommendation) Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 10 6. Treatment of hypoalbuminemia without signs of edema or hypotension55-57 (UW Health low quality evidence; weak/conditional recommendation) 7. Preoperative hemodilution61 (UW Health low quality evidence; weak/conditional recommendation) 8. Fluid expansion in the immediate postoperative period following minor surgery (UW Health very low quality evidence; weak/conditional recommendation) 9. Treatment of aneurysmal subarachnoid hemorrhage62 (UW Health low quality evidence; weak/conditional recommendation) 10. To treat diuretic resistance in patients who do not meet criteria as defined above (UW Health low quality evidence; weak/conditional recommendation) Monitoring of albumin administration Continued need for albumin administration should be assessed daily. Albumin should be discontinued as soon as therapy is no longer required according to monitored parameters. (UW Health low quality evidence; strong recommendation) 1. Laboratory a. Albumin therapy may not be necessary in patients with plasma albumin ≥2.5 g/dL 2. Physical assessment: consider discontinuing albumin when goal is reached a. Blood pressure: SBP >100 mmHg or MAP >60 mmHg b. Urine output: >0.5 mL/kg/hour c. Improvement in condition(s) for which albumin was initiated d. Edema improvement (total body fluid overload and intravascular volume depletion) e. Other measures of fluid responsiveness UW Health Implementation Potential Benefits: Implementation of and adherence to the guideline recommendations should result in use of albumin that is consistent, evidence-based, and cost effective Potential Harms: Patients may experience adverse effects to albumin, even when receiving it for an approved indication and at a recommended dose Pertinent UW Health Policies & Procedures 1. Nursing Policy #11.10: Percutaneous Paracentesis 2. Nursing Policy #1.01AP: Therapeutic Plasma Exchange Patient Resources 1. Health Facts For You #5790: Transplant desensitization with plasma exchange and IVIG Guideline Metrics 1. Periodic medication use evaluation of albumin to assess outcomes, including mortality, adverse effects, and cost. Order Sets • IP - General Care - Adult [692] • Anesthesiology - Adult - Recovery/PACU [1396] • IP - Anesthesiology - ICU - Adult - Postoperative [2952] • IP - Cirrhosis - Adult - Admission [1673] • IP - ECMO - Adult - Post-Cannulation [2459] • IP - Hemodialysis - Adult - Procedure [5138] • DHC - Body - Paracentesis - Adult - Postprocedure [5398] • IP - Body - Paracentesis - Adult - Postprocedure [1607] • IP - Paracentesis - Bedside - Adult - Pre/Postprocedure [2469] • IP - Donor Hepatic Lobectomy - Adult - Postoperative [2884] • IP - Pancreas Transplant - Adult - Postoperative [2889] Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 11 • IP - Renal/Pancreas Transplant - Adult - Postoperative [2927] • IP - Comprehensive Brain Dead Donor (BDD) Delegation Protocol - Adult - Intensive Care - Supplemental [4078] • IP - Comprehensive Donation After Cardiac Death (DCD) - Adult - Intensive Care - Supplemental [3627] Disclaimer Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. Appendix A. Evidence Grading Scheme(s) Figure 1. GRADE Methodology adapted by UW Health GRADE Ranking of Evidence High We are confident that the effect in the study reflects the actual effect. Moderate We are quite confident that the effect in the study is close to the true effect, but it is also possible it is substantially different. Low The true effect may differ significantly from the estimate. Very Low The true effect is likely to be substantially different from the estimated effect. GRADE Ratings for Recommendations For or Against Practice Strong The net benefit of the treatment is clear, patient values and circumstances are unlikely to affect the decision. Weak/conditional Recommendation may be conditional upon patient values and preferences, the resources available, or the setting in which the intervention will be implemented. Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 12 References 1. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. Feb 28 2013;(2):Cd000567. doi:10.1002/14651858.CD000567.pub6 2. Charles A, Purtill M, Dickinson S, et al. Albumin use guidelines and outcome in a surgical intensive care unit. Arch Surg. Oct 2008;143(10):935-9; discussion 939. doi:10.1001/archsurg.143.10.935 3. Nadim MK, Durand F, Kellum JA, et al. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. J Hepatol. Mar 2016;64(3):717-35. doi:10.1016/j.jhep.2015.10.019 4. Caraceni P, Angeli P, Prati D, et al. AISF-SIMTI position paper: the appropriate use of albumin in patients with liver cirrhosis. Blood Transfus. Jan 2016;14(1):8-22. doi:10.2450/2016.0294-15 5. Liumbruno GM, Bennardello F, Lattanzio A, et al. Recommendations for the use of albumin and immunoglobulins. Blood Transfus. Jul 2009;7(3):216-34. doi:10.2450/2009.0094-09 6. Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. American Association for the Study of Liver Diseases 2016. https://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf 7. Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. Apr 2015;64(4):531-7. doi:10.1136/gutjnl-2014-308874 8. Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. Sep 2007;56(9):1310-8. doi:10.1136/gut.2006.107789 9. Runyon BA, Aasld. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. Apr 2013;57(4):1651-3. doi:10.1002/hep.26359 10. Gluud LL, Christensen K, Christensen E, Krag A. Systematic review of randomized trials on vasoconstrictor drugs for hepatorenal syndrome. Hepatology. Feb 2010;51(2):576-84. doi:10.1002/hep.23286 11. Skagen C, Einstein M, Lucey MR, Said A. Combination treatment with octreotide, midodrine, and albumin improves survival in patients with type 1 and type 2 hepatorenal syndrome. J Clin Gastroenterol. Aug 2009;43(7):680-5. doi:10.1097/MCG.0b013e318188947c 12. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. Aug 5 1999;341(6):403-9. doi:10.1056/NEJM199908053410603 13. Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol. Feb 2013;11(2):123-30 e1. doi:10.1016/j.cgh.2012.11.007 14. Bernardi M CP, Navickis RJ, et al. Albumin Infusion in Patients Undergoing Large-Volume Paracentesis: A Meta-Analysis of Randomized Trials. Hepatology. 2012;55(4):1172-1181. 15. Alessandria C, Elia C, Mezzabotta L, et al. Prevention of paracentesis-induced circulatory dysfunction in cirrhosis: standard vs half albumin doses. A prospective, randomized, unblinded pilot study. Dig Liver Dis. Nov 2011;43(11):881-6. doi:10.1016/j.dld.2011.06.001 16. Anderson SS, McCreary JB, Alvarez KS, Brown LS, Agrawal D. Standardizing the Use of Albumin in Large Volume Paracentesis. J Pharm Pract. Aug 2020;33(4):420-424. doi:10.1177/0897190018816252 17. Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. Aug 2021;74(2):1014-1048. doi:10.1002/hep.31884 18. Lasky LC, Finnerty EP, Genis L, Polesky HF. Protein and colloid osmotic pressure changes with albumin and/or saline replacement during plasma exchange. Transfusion. May-Jun 1984;24(3):256-9. 19. Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. Apr 10 2014;370(15):1412-21. doi:10.1056/NEJMoa1305727 20. Delaney AP, Dan A, McCaffrey J, Finfer S. The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Crit Care Med. Feb 2011;39(2):386-91. doi:10.1097/CCM.0b013e3181ffe217 21. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. May 27 2004;350(22):2247-56. doi:10.1056/NEJMoa040232 22. Investigators SS, Finfer S, McEvoy S, et al. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med. Jan 2011;37(1):86-96. doi:10.1007/s00134-010-2039-6 23. Xu JY, Chen QH, Xie JF, et al. Comparison of the effects of albumin and crystalloid on mortality in adult patients with severe sepsis and septic shock: a meta-analysis of randomized clinical trials. Crit Care. Dec 15 2014;18(6):702. doi:10.1186/s13054- 014-0702-y 24. Patel A, Laffan MA, Waheed U, Brett SJ. Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality. BMJ. Jul 22 2014;349:g4561. doi:10.1136/bmj.g4561 25. Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. Nov 6 2013;310(17):1809-17. doi:10.1001/jama.2013.280502 26. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. Mar 2017;45(3):486-552. doi:10.1097/CCM.0000000000002255 27. Liberati A, Moja L, Moschetti I, Gensini GF, Gusinu R. Human albumin solution for resuscitation and volume expansion in critically ill patients. Intern Emerg Med. 2006;1(3):243-5. 28. Gentilini P, Bernardi M, Bolondi L, et al. The rational use of albumin in patients with cirrhosis and ascites. A Delphi study for the attainment of a consensus on prescribing standards. Dig Liver Dis. Aug 2004;36(8):539-46. 29. Gentilini P, Casini-Raggi V, Di Fiore G, et al. Albumin improves the response to diuretics in patients with cirrhosis and ascites: results of a randomized, controlled trial. J Hepatol. Apr 1999;30(4):639-45. 30. Chalasani N, Gorski JC, Horlander JC, Sr., et al. Effects of albumin/furosemide mixtures on responses to furosemide in hypoalbuminemic patients. J Am Soc Nephrol. May 2001;12(5):1010-6. 31. Gines P, Cardenas A, Arroyo V, Rodes J. Management of cirrhosis and ascites. N Engl J Med. Apr 15 2004;350(16):1646-54. doi:10.1056/NEJMra035021 Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 13 32. Romanelli RG, La Villa G, Barletta G, et al. Long-term albumin infusion improves survival in patients with cirrhosis and ascites: an unblinded randomized trial. World J Gastroenterol. Mar 7 2006;12(9):1403-7. 33. Kitsios GD, Mascari P, Ettunsi R, Gray AW. Co-administration of furosemide with albumin for overcoming diuretic resistance in patients with hypoalbuminemia: a meta-analysis. J Crit Care. Apr 2014;29(2):253-9. doi:10.1016/j.jcrc.2013.10.004 34. Brater DC. Diuretic therapy. N Engl J Med. Aug 06 1998;339(6):387-95. doi:10.1056/NEJM199808063390607 35. Caraceni P, Riggio O, Angeli P, et al. Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial. Lancet. Jun 16 2018;391(10138):2417-2429. doi:10.1016/s0140-6736(18)30840-7 36. China L, Freemantle N, Forrest E, et al. A Randomized Trial of Albumin Infusions in Hospitalized Patients with Cirrhosis. N Engl J Med. Mar 4 2021;384(9):808-817. doi:10.1056/NEJMoa2022166 37. Worm AM, Taaning E, Rossing N, Parving HH, Clemmensen OJ. Distribution and degradation of albumin in extensive skin disease. Br J Dermatol. Apr 1981;104(4):389-96. 38. Gore DC, Dalton JM, Gehr TW. Colloid infusions reduce glomerular filtration in resuscitated burn victims. J Trauma. Mar 1996;40(3):356-60. 39. Roberts I, Blackhall K, Alderson P, Bunn F, Schierhout G. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. Nov 09 2011;(11):Cd001208. doi:10.1002/14651858.CD001208.pub4 40. Cochran A, Morris SE, Edelman LS, Saffle JR. Burn patient characteristics and outcomes following resuscitation with albumin. Burns. Feb 2007;33(1):25-30. doi:10.1016/j.burns.2006.10.005 41. Sedrakyan A, Gondek K, Paltiel D, Elefteriades JA. Volume expansion with albumin decreases mortality after coronary artery bypass graft surgery. Chest. Jun 2003;123(6):1853-7. 42. Russell JA, Navickis RJ, Wilkes MM. Albumin versus crystalloid for pump priming in cardiac surgery: meta-analysis of controlled trials. J Cardiothorac Vasc Anesth. Aug 2004;18(4):429-37. 43. Johnson PN, Romanelli F, Smith KM, Ranjan D, Butler JS, Clifford TM. Analysis of morbidity in liver transplant recipients following human albumin supplementation: a retrospective pilot study. Prog Transplant. Sep 2006;16(3):197-205. 44. Mukhtar A ME, Metini M, et al. The Impact of Maintaining Normal Serum Albumin Level Following Liver Related Liver Transplantation: Does Serum Albumin Level Affect the Course? A Pilot Study. Transplantation Proceedings. 2007;39:3214- 3218. 45. Yoshimura A, Ideura T, Iwasaki S, Taira T, Koshikawa S. Aggravation of minimal change nephrotic syndrome by administration of human albumin. Clin Nephrol. Mar 1992;37(3):109-14. 46. Akcicek F, Yalniz T, Basci A, Ok E, Mees EJ. Diuretic effect of frusemide in patients with nephrotic syndrome: is it potentiated by intravenous albumin? BMJ. Jan 21 1995;310(6973):162-3. 47. Fliser D, Zurbruggen I, Mutschler E, et al. Coadministration of albumin and furosemide in patients with the nephrotic syndrome. Kidney Int. Feb 1999;55(2):629-34. doi:10.1046/j.1523-1755.1999.00298.x 48. Martin GS MM, Wheeler AP, et al. A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury. Crit Care Med. 2005;33(8):1681-1687. 49. Uhlig C, Silva PL, Deckert S, Schmitt J, de Abreu MG. Albumin versus crystalloid solutions in patients with the acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care. 2014;18(1):R10. doi:10.1186/cc13187 50. Martin GS, Mangialardi RJ, Wheeler AP, Dupont WD, Morris JA, Bernard GR. Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury. Crit Care Med. Oct 2002;30(10):2175-82. doi:10.1097/01.CCM.0000025182.51800.ED 51. Knoll GA, Grabowski JA, Dervin GF, O'Rourke K. A randomized, controlled trial of albumin versus saline for the treatment of intradialytic hypotension. J Am Soc Nephrol. Feb 2004;15(2):487-92. 52. Fortin PM, Bassett K, Musini VM. Human albumin for intradialytic hypotension in haemodialysis patients. Cochrane Database Syst Rev. 2010;(11):CD006758. doi:10.1002/14651858.CD006758.pub2 53. Powner DJ, Darby JM. Management of variations in blood pressure during care of organ donors. Prog Transplant. Mar 2000;10(1):25-30; quiz 31-2. 54. Investigators. TSS. Saline or Albumin for Fluid Resuscitation in Patinets with Traumatic Brian Injury. N Engl J Med. 2007;357(9):874-884. 55. Dubois MJ, Orellana-Jimenez C, Melot C, et al. Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study. Crit Care Med. Oct 2006;34(10):2536-40. doi:10.1097/01.CCM.0000239119.57544.0C 56. Yuan XY, Zhang CH, He YL, et al. Is albumin administration beneficial in early stage of postoperative hypoalbuminemia following gastrointestinal surgery?: a prospective randomized controlled trial. Am J Surg. Nov 2008;196(5):751-5. doi:10.1016/j.amjsurg.2007.10.030 57. Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med. Aug 7 2001;135(3):149-64. 58. Vermeulen LC, Jr., Ratko TA, Erstad BL, Brecher ME, Matuszewski KA. A paradigm for consensus. The University Hospital Consortium guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. Arch Intern Med. Feb 27 1995;155(4):373-9. 59. Boldt J. Use of albumin: an update. Br J Anaesth. Mar 2010;104(3):276-84. doi:10.1093/bja/aep393 60. Simon-Talero M, Garcia-Martinez R, Torrens M, et al. Effects of intravenous albumin in patients with cirrhosis and episodic hepatic encephalopathy: a randomized double-blind study. J Hepatol. Dec 2013;59(6):1184-92. doi:10.1016/j.jhep.2013.07.020 61. Jones SB, Whitten CW, Monk TG. Influence of crystalloid and colloid replacement solutions on hemodynamic variables during acute normovolemic hemodilution. J Clin Anesth. Feb 2004;16(1):11-7. doi:10.1016/j.jclinane.2003.03.003 62. Suarez JI, Martin RH, Calvillo E, et al. The Albumin in Subarachnoid Hemorrhage (ALISAH) multicenter pilot clinical trial: safety and neurologic outcomes. Stroke. Mar 2012;43(3):683-90. doi:10.1161/STROKEAHA.111.633958 Effective 06/22/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Scope Methodology Definitions Introduction Recommendations UW Health Implementation Appendix A. Evidence Grading Scheme(s) References