Albumin usage and dosing in sepsis
10 Feb 2026
Recent clinical trials and protocols (2024–2025) for managing septic shock use 20% albumin primarily as a second-line therapy when patients remain hypotensive despite initial crystalloid resuscitation (30mL/kg).
Current dosage protocols for 20% albumin in septic shock focus on two main strategies: bolus resuscitation for hemodynamic stability and maintenance to target specific serum albumin levels.
1. Bolus Resuscitation Protocols (Early Shock Reversal)
In the early phases of septic shock, especially in emergency department (ED) settings, high-concentration albumin is given in discrete boluses:
Initial Resuscitation: 200 mL of 20% albumin combined with 15 mL/kg of crystalloid, typically administered over 1–2 hours.
Standard Dosing: 0.5 to 1 g/kg per dose (equivalent to 2.5 to 5 mL/kg of 20% solution).
Cirrhosis and Sepsis-Induced Hypotension: 0.5 to 1.0 g/kg of 20% albumin infused over 3 hours has been used specifically to achieve faster improvement in MAP and lactate clearance.
2. Maintenance and Targeted Albumin Protocols
Recent trials such as ALBIOS and ALBUS emphasize maintaining serum albumin at specific physiological thresholds to improve outcomes:
Maintenance Target: Aiming for a serum albumin level $\ge 3.0\text{ g/dL (30 g/L)}$.
Surgical Septic Shock (ALBUS Protocol): 20% human albumin solution is used to maintain concentrations above 3.5 g/dL for up to 72 hours.
Dosing Adjustments Based on Levels:
Level < 20 g/L: 80 g of 20% albumin over 3–4 hours.
Level 20–25 g/L: 60 g over 2–3 hours.
Level 25–30 g/L: 40 g over 1–2 hours.
Evidence-Based Maintenance: 20 grams every 8 hours for 3 days as an adjuvant to crystalloid resuscitation in hypoalbuminemic patients.
3. Clinical Administration and Safety Limits
Infusion Rate: For hypoalbuminemic patients, the rate should generally not exceed 2 mL per minute to prevent circulatory overload and pulmonary edema. (The UK Sepsis trust Guildeline 2024)
Volume Expansion Effect: 20% albumin is hyperoncotic; 100 mL can expand plasma volume by 3–4 times (approx. 400 mL) within 20–30 minutes by drawing fluid from the interstitial spaces.
Monitoring Requirements: Protocols mandate continuous monitoring for signs of fluid overload (e.g., bilateral crepitations or raised Central Venous Pressure > 15 mmHg).
Dilution Warning: If diluted, only use 0.9% sodium chloride or 5% dextrose; never use water as it causes intravascular hemolysis.
Caironi, P., Tognoni, G., Masson, S., Fumagalli, R., Pesenti, A., Romero, M., Fanizza, C., Caspani, L., Faenza, S., Grasselli, G., Iapichino, G., Antonelli, M., Parrini, V., Fiore, G., Latini, R., & Gattinoni, L. (2014). Albumin replacement in patients with severe sepsis or septic shock. New England Journal of Medicine, 370(15), 1412–1421.
Catalisano, G., Ippolito, M., Blanda, A., Meessen, J., Giarratano, A., Todesco, N., Bonato, V., Restuccia, F., Montomoli, J., Fiore, G., Grasselli, G., Caironi, P., Latini, R., & Cortegiani, A. (2024). Effects of hyperoxemia in patients with sepsis – A post-hoc analysis of a multicentre randomized clinical trial. Pulmonology, 31.
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., McIntyre, L., Ostermann, M., Prescott, H. C., et al. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063–e1143.
Sun, J. K., Sun, F., Wang, X., Yuan, S. T., Zheng, S. Y., & Mu, X. W. (2015). Risk factors and prognosis of hypoalbuminemia in surgical septic patients. PeerJ, 3, e1267.
Yu, Y. T., Liu, J., Hu, B., Wang, R. L., Yang, X. H., Shang, X. L., Wang, G., Wang, C. S., Li, B. L., Gong, Y., et al. (2021). Expert consensus on the use of human serum albumin in critically ill patients. Chinese Medical Journal, 134(14), 1639–1654.
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Sepsis Management - A Quick Guide for LMIC (update 2024)
15 Sept 2023
Our ebook for sepsis management in our local setting 2nd edition was published!
Confused about how to identify sepsis?
Confused about how and when to use qSOFA score?
But eager to know the cheapest and simplest ways to monitor and manage sepsis in a busy and limited resources setting?
"Sepsis Management: A Quick Guide", this ebook is customized to suit our local setting and other low-middle income countries to provide you with the answer.
The book contains side-by-side illustrations with texts to unfold the complexity of sepsis and is easy to understand. It also contains important pitfalls and tips for managing sepsis. Furthermore, the book is also equipped with Google translation tool to accommodate readers of different languages.
This book is suitable for:
1. Doctors who work in the district, Emergency Departments, ICU, and Critical care units. It is also suitable for Infectious disease specialists, pharmacists, and healthcare providers, especially those from low-middle-income countries.
2. Paramedics and Nursing personnel.
3. Scientists who are currently doing or wishing to do clinical research in sepsis.
For Android: https://shorturl.at/dktwV
For iOS: please download Google play book for ios:
https://apps.apple.com/us/app/google-play-books-audiobooks/id400989007
.jpg)
Finally, our ebook for sepsis management in our local setting was published! 31 July 2019
Confuse about how to identify sepsis?
Confuse about how and when to use qSOFA score?
But eager to know the cheapest and simplest ways to monitor and manage sepsis in a busy and limited resources setting?
"Sepsis Management: A Quick Guide", this ebook is customised to suit our local setting and other low-middle income countries to provide you with the answer.
The book contains side by side illustrations with texts to unfold the complexity of sepsis and easy to understand. It also contains important pitfalls and tips while managing sepsis. Furthermore, the book is also equiped with google translation tool to accommodate readers of different languages.
This book is suitable for:
1. Doctors who work in district, Emergency Departments, ICU and Critical care unit. It also suitable for Infection disease specialists, pharmacists and healthcare providers, especially those from low-middle income countries.
2. Paramedics and Nursing personals.
3. Scientists who is currently doing or wishing to do clinical research in sepsis.
Get a copy at Google Play Book Store with offer price at this link. (support for both ios and android user)
https://books.google.com.my/books/about?id=rvSiDwAAQBAJ&redir_esc=y
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27 Jun 2019
Sepsis Resuscitation and Monitoring Chart (SRMC) in Low-Middle Income Country Setting
Link to download
PDF: https://drive.google.com/file/d/1RZNZFn6-4-5pdHds6lZrh463Mc_z4-kB/view?usp=sharing
PNG: https://drive.google.com/file/d/1GO4cD4FXJpl3txSDHTUAwww-siVlk-Ma/view?usp=sharing
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8 Oct 2019
The Relevance of Drug Volume of Distribution in Antibiotic Dosing
Sepsis and the Systemic Inflammatory Response Syndrome (SIRS)
Abstract The judicious use of existing antibiotics is essential for preserving their activityagainst infections. In the era of multi-drug resistance, this is of particular importance in clin-ical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimizationin critically ill patients requires sound knowledge not only of the altered physiology in seri-ous infections --- including severe sepsis, septic shock and ventilator-associated pneumonia ---but also of the pathogen---drug exposure relationship (i.e. pharmacokinetic/pharmacodynamicindex). An important consideration is the fact that extreme shifts in organ function, such asthose seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, canhave an impact upon drug exposure, and constant vigilance is required when reviewing antibi-otic dosing regimens in the critically ill. The use of continuous renal replacement therapy andextracorporeal membrane oxygenation remain important interventions in these patients; how-ever, both of these treatments can have a profound effect on antibiotic exposure. We suggestplacing emphasis on the use of therapeutic drug monitoring and dose individualization whenoptimizing therapy in these settings.
Another common phenomenon soon after the ini-tial phase of severe sepsis and septic shock is thepronounced reduction in serum albumin concentrations(hypoalbuminemia).23Albumin constitutes nearly two-thirdsof all human serum proteins and is the primary proteinresponsible for drug-protein binding.24Previously defined asa serum albumin concentration less than 25 g/L,25hypoal-buminemia has a direct impact on the PK of antibiotics,particularly on those antibiotics that are highly proteinbound.26Firstly, it increases the unbound or ‘free’ frac-tion of drug. This is important given that it is only theunbound drug that can exert a pharmacodynamic effect.As hypoalbuminemic states can increase the amount ofdrug that distributes into tissues, this is likely to havea direct effect on the Vdof an antibiotic. Finally, asonly the unbound drug in the intravascular compartmentis available for metabolism and elimination, low serumalbumin concentrations may mean that there is higher pro-portion of unbound drug available for clearance leadingto low concentrations toward the end of the dosing inter-val.
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17 Oct 2018
Vitamin C, Thiamin and Steriod improve organ failure
The components of Marik’s life-saving sepsis cocktail are simply steroids and vitamins, a therapy, which many have said is harmless, but may improve sepsis survival dramatically. Steroids for sepsis have been around decades, and although there have been several trials evaluating its benefits in the septic patient; it is safe to say that the use of steroids remains controversial. The recently completed HYPRESS trial did not demonstrate a benefit for steroids in patients with sepsis. How about the use of vitamin C and thiamine? This is not a new concept and there are studies demonstrating benefit so perhaps, combining all these “harmless” therapies would work on the deranged physiologic pathways that are present in the septic patient.
So the conjecture here is that Marik’s new cocktail has little patient harm because the individual components are individually benign and have been studied before. In fact, Marik himself has made the claim that withholding this therapy while waiting for a multicenter trial to be completed would be unethical. In support of his statement he has even invoked the infamous “parachute analogy” where some therapies are so obvious that it would be illogical to test them in a clinical trial.
Abstract
Adapted from (Marik et al 2016)
Background: The global burden of sepsis is estimated as 15 to 19 million cases annually with a mortality rate approaching 60% in low income countries.
Methods: In this retrospective before-after clinical study, we compared the outcome and
clinical course of consecutive septic patients treated with intravenous vitamin C,
hydrocortisone and thiamine during a 7-month period (treatment group) compared to a
control group treated in our ICU during the preceding 7 months. The primary outcome was
hospital survival. A propensity score was generated to adjust the primary outcome.
Findings: There were 47 patients in both treatment and control groups with no significant
differences in baseline characteristics between the two groups. The hospital mortality was
8.5% (4 of 47) in the treatment group compared to 40.4% (19 of 47) in the control group (p
< 0.001). The propensity adjusted odds of mortality in the patients treated with the vitamin
C protocol was 0.13 (95% CI 0.04-0.48, p=002). The SOFA score decreased in all patients in
the treatment group with none developing progressive organ failure. Vasopressors were
weaned off all patients in the treatment group, a mean of 18.3 ± 9.8 hours after starting
treatment with vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4
hours in the control group (p<0.001).
Conclusion: Our results suggest that the early use of intravenous vitamin C, together with
corticosteroids and thiamine may prove to be effective in preventing progressive organ
dysfunction including acute kidney injury and reducing the mortality of patients with
severe sepsis and septic shock. Additional studies are required to confirm these
preliminary findings.
The clinical trial paper can be found at this link:
https://digitalcommons.odu.edu/cgi/viewcontent.cgi?article=1127&context=bioelectrics_pubs
For those who want to get a quick glance on this topic, please kindly go to this link (credits to R.E.B.E.L EM group making the topic easy to understand):
http://rebelem.com/the-marik-protocol-have-we-found-a-cure-for-severe-sepsis-and-septic-shock/
MSOFA: An Important Step Forward, but Are We Spending Too Much Time on the SOFA?
SEPSIS 3 recommended the use of SOFA score to assess the organ failure status. However, the criteria are quite complex. We recommend the use of modified SOFA to adapt to the local minimum setting.
The mortality rate was 9% for patients with no organ failure on admission, increasing to 82.6% for patients with four or more failing organs.
When two organ systems were failing, as defined by a SOFA score of 3 or 4, the presence of respiratory failure as one of the two failing systems was associated with a lower mortality rate than any other combination. For combinations of other organs, there was a narrow range of mortality (65% to 74%), and no identifiable pattern of increased risk with any specific organ.
SOFA Score
|
Mortality if initial score
|
Mortality if highest score
|
0-1
|
0.0%
|
0.0%
|
2-3
|
6.4%
|
1.5%
|
4-5
|
20.2%
|
6.7%
|
6-7
|
21.5%
|
18.2%
|
8-9
|
33.3%
|
26.3%
|
10-11
|
50.0%
|
45.8%
|
12-14
|
95.2%
|
80.0%
|
>14
|
95.2%
|
89.7%
|
Mean SOFA Score
|
Mortality
|
0-1.0
|
1.2%
|
1.1-2.0
|
5.4%
|
2.1-3.0
|
20.0%
|
3.1-4.0
|
36.1%
|
4.1-5.0
|
73.1%
|
>5.1
|
84.4%
|
To download this file please follow this link :
powerpoint : https://drive.google.com/open?id=1j1bGoA7yAv4cshuLqR9_qcnM8VIAyx5H
png file : https://drive.google.com/open?id=19UczWkza9U6udO-oBxUn8vVjjU1qRyxN
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15 August 2018
The BMJ
WHAT YOU NEED TO KNOW
• Sepsis is a syndrome of life threatening infection with organ dysfunction, and most guidelines do not advise use of corticosteroids to treat it in the absence of refractory shock
• Two new trials of corticosteroid treatment for sepsis came to differing conclusions
• Corticosteroids may reduce the risk of death by a small amount and increase neuromuscular weakness by a small amount, but the evidence is not definitive
• This guideline makes a weak recommendation for corticosteroids in patients with sepsis; both steroids and no steroids are reasonable management options
• Fully informed patients who value avoiding death over quality of life and function would likely choose corticosteroids
For Further Reading, please go to the follow link
https://www.bmj.com/content/362/bmj.k3284
Acknowledgement to The BMJ for permission for non profit reused.
Surviving Sepsis Campaign Hour-1 Bundle 2018
