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Blood Transfusion

Albumin Administration

  • Paediatric Albumin Guidance 

    This document guides how to prescribe, administer and manage paediatric patients receiving intravenous albumin at the RCH.

    Albumin comes in two concentrations: Alburex®5 (5%) and Alburex®20 (20%). 

     Preparation  Alburex 5% (50 g/L)  Alburex 20% (200 g/L)
     Concentration   1g human albumin/20ml  1g human albumin/5mls
     Description   Mildly hypo-oncotic   Hyper-oncotic and hypo-osmotic *
     Vial size
    • 12.5g human albumin/250mL vial
    • 25g human albumin/500mL vial
    • 2g human albumin/10mls
    • 20g human albumin/100mls
     Use   Use in hypovolaemic or intravascularly deplete patients  Use in patients with fluid or sodium restrictions 
     Contraindication  Patients with history of anaphylaxis to albumin or constituents  
     Caution  The minimum vial size has changed from 50mL to 250mL  Extreme caution in preterm neonates, due to intraventricular haemorrhage risk.
     Children with precarious fluid balance status *

    *Alburex 20% is both hyper-oncotic and hypo-osmotic compared with Albumex 20% (only hyper-oncotic). Therefore, there is higher risk of acute fluid shifts between physiological compartments.

    Additional details on comparisons between Alburex 20% and Albumex 20%. 

    Indications, dosing and infusion rates

    5% Albumin 

     5% Albumin clinical indications 
     Fluid resuscitation (not first line – use crystalloids)  Significant hypoalbuminemia 
     Nephrotic syndrome  Therapeutic plasma exchange
     Cardiopulmonary bypass pump prime  Excessive protein losses/replacement of drain losses 
     Burns fluid management  Liver transplant post-operative management 
     Post cardiac surgery chylothorax management   


     5% Albumin dosing and infusion guide for children
       Dose (g)  Dose (mL)   Infusion duration guide 
     Hypotension  0.5 g/kg  12.5 mL/kg  15 to 20 minutes
     Hypovolaemia, plasma volume expansion   0.5 g – 1g/kg
    • 12.5 – 25 mL/kg
    • Older child 250 to 500 mL
    		  30 - 60 minutes (slower rates in neonates)
     Hypovolaemic shock   0.5 g – 1 g/kg  12.5 - 25 mL/kg  5 - 10 minutes
     Hypoproteinaemia  0.5g – 1 g/kg  12.5 – 25 mL/kg  2 - 4 hours
     Large volume paracentesis  0.5g – 1 g/kg  12.5 – 25 mL/kg  Over 1 - 2 hours after paracentesis


    20% Albumin 

    20% Albumin clinical indications
    Nephrotic syndrome Children with severe liver disease and ascites
    Liver failure Plasmapheresis when a patient’s albumin is not maintained with 5% albumin solution
    Haemolytic disease of the fetus and newborn Children with significant chylothorax
    Post-operative liver transplant management  


    20% Albumin dosing and infusion guide in children
      Dose (g) Infusion duration guide*
    Nephrotic syndrome, refractory 0.5 – 1 g/kg Over 30 – 60 minutes followed by diuretics
    Large volume paracetensesis 0.5 – 1 g/kg Over 1-2 hours after paracentesis
    Haemolytic disease of the fetus and newborn 1 g/kg/dose Prior to or during plasma exchange
    Ascites with hypoalbuminaemia 1 g/kg/dose Over 2- 3 hours

    * Caution – too rapid administration can result in vascular overload. 

    Consent, prescription, administration, reactions and adverse events

    Consent and patient information

    • Albumin is a plasma-derived blood product. The risk of viral transmission is exceptionally low.
    • Consent must be documented on the Patient consent to blood products MR634/A form prior to administration.
    • CSL Consumer Medicine information:

    Prescription

    Prescription / order must contain:
    - Concentration (5% or 20%) - Dose (g) / volume (mL)
    - Route (IV) - Frequency (stat / bolus) or recurrent bolus*
    - Duration of infusion (maximum 6 hours) *  

    * Albumin may be prescribed as a bolus dose or a continuous infusion (in this instance it should be prescribed as a regular administration (e.g., every 6 hours)

    Administration  

    Pre-infusion
    Two staff perform double independent checks of patient, product and prescription at the patient bedside. This includes:
    - Correct product and concentration (5% vs 20%) - Dose / volume and rate specified and appropriate for patient.
    - Expiry date - Integrity of the product
    - Dual sign and record the batch number and expiry date of each bottle infused in medical record.


    Other administration considerations

    - Albumin does not contain any antimicrobial preservative. The manufacturer recommends that each bottle be used immediately after opening.

    - At RCH we allow the product to be administered within 6 hours of piercing the bottle.

    - Administer via a standard intravenous (IV) giving set. It does not require a transfusion filter. - Must be vented during infusion.
    - Use an infusion pump with careful consideration of rate and total volume to be infused to prevent over infusion. - Caution – the minimum vial size has changed from 50 to 250 mL.
    - Albumin is a clear liquid that may have a yellow or slight green tinge. - If cloudy or noted to have precipitation return to blood bank.  

    - Do not mix with any medications.  

    - Albumin may be infused with red cells and ABO compatible plasma. 

    		 - Do not be dilute with water for injections, this may cause haemolysis.
    - Return to blood bank immediately if no longer required. - Any unused product must be discarded.
    - Do not place in ward drug fridges or allow to remain at patient’s bedside.


    Observations and monitoring    

    Carefully monitor the patient for circulatory overload, especially in relation to Alburex 20% due to the colloid osmotic effect. Minimum observations include: 

    Time point Observations
    Baseline Temperature, pulse, respiratory rate, blood pressure, SaO2
    Hourly until transfusion is completed Temperature, pulse, respiratory rate, blood pressure, SaO2 and IV pump volume/volume infused.
    Conclusion


    Reactions, adverse events and near misses

    • Reactions to albumin solutions are usually mild and transient.
    • Mild reactions such as mild hypotension, flushing, urticaria, fever and nausea usually disappear when the infusion rate is slowed or ceased.
    • Very rarely, severe allergic reactions such as anaphylaxis or significant hypotension can occur. In these instances, the albumin infusion should be stopped and appropriate emergency treatment provided (IM adrenaline for anaphylaxis and IV fluids for hypotension).
    • Manage and report reactions as per the Blood Transfusion – Fresh Blood Products Procedure 
    • Report any adverse events or near miss via VHIMS.