Albuked 25%

Emergency Treatment of Hypovolemic Shock

Albuked 25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. (1) If the patient is dehydrated, additional crystalloids must be given, (4) or alternatively, Albumin (Human) 5%, USP (Albuked™ 5) should be used. The patient’s hemodynamic response should be monitored and the usual precautions against circulatory overload observed. The total dose should not exceed the level of albumin found in the normal individual, i.e., about 2 g per kg body weight in the absence of active bleeding. Although Albuked 5 is to be preferred for the usual volume deficits, Albuked 25 with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed. (2)

Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume. (2)

Burn Therapy

An optimal therapeutic regimen with respect to the administration of colloids, crystalloids, and water following extensive burns has not been established. During the first 24 hours after sustaining thermal injury, large volumes of crystalloids are infused to restore the depleted extracellular fluid volume. Beyond 24 hours Albuked 25 can be used to maintain plasma colloid osmotic pressure.

Hypoproteinemia With or Without Edema

During major surgery, patients can lose over half of their circulating albumin with the attendant complications of oncotic deficit. (2,4,5) A similar situation can occur in sepsis or intensive care patients. Treatment with Albuked 25 may be of value in such cases. (2)

Adult Respiratory Distress Syndrome (ARDS) (2,5)

This is characterized by deficient oxygenation caused by pulmonary interstitial edema complicating shock and postsurgical conditions. When clinical signs are those of hypoproteinemia with a fluid volume overload, Albuked 25 together with a diuretic may play a role in therapy.

Cardiopulmonary Bypass (2,6)

With the relatively small priming volume required with modern pumps, preoperative dilution of the blood using albumin and crystalloid has been shown to be safe and well-tolerated. Although the limit to which the hematocrit and plasma protein concentration can be safely lowered has not been defined, it is common practice to adjust the albumin and crystalloid pump prime to achieve a hematocrit of 20% and a plasma albumin concentration of 2.5 g per 100 mL in the patient.

Acute Liver Failure (2)

In the uncommon situation of rapid loss of liver function with or without coma, administration of albumin may serve the double purpose of supporting the colloid osmotic pressure of the plasma as well as binding excess plasma bilirubin.

Neonatal Hemolytic Disease (2,3)

The administration of Albuked 25 may be indicated prior to exchange transfusion, in order to bind free bilirubin, thus lessening 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.

Sequestration of Protein Rich Fluids (7)

This occurs in such conditions as acute peritonitis, pancreatitis, mediastinitis, and extensive cellulitis. The magnitude of loss into the third space may require treatment of reduced volume or oncotic activity with an infusion of albumin.

Erythrocyte Resuspension (2)

Albumin may be required to avoid excessive hypoproteinemia, during certain types of exchange transfusion, or with the use of very large volumes of previously frozen or washed red cells. About 25 g of albumin per liter of erythrocytes is commonly used, although the requirements in preexistent hypoproteinemia or hepatic impairment can be greater. Albuked 25 is added to the isotonic suspension of washed red cells immediately prior to transfusion.

Acute Nephrosis (2)

Certain patients may not respond to cyclophosphamide or steroid therapy. The steroids may even aggravate the underlying edema. In this situation a loop diuretic and 100 mL Albuked 25 repeated daily for 7 to 10 days may be helpful in controlling the edema and the patient may then respond to steroid treatment.

Renal Dialysis (2)

Although not part of the regular regimen of renal dialysis, Albuked 25 may be of value in the treatment of shock or hypotension in these patients. The usual volume administered is about 100 mL, taking particular care to avoid fluid overload as these patients are often fluid overloaded and cannot tolerate substantial volumes of salt solution.

Situations in Which Albumin Administration is Not Warranted (2)

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. It is of occasional use in the rapid “priming” diuresis of nephrosis. Similarly, in hypoproteinemic states associated with chronic cirrhosis, malabsorption, protein losing enteropathies, pancreatic insufficiency, and undernutrition, the infusion of albumin as a source of protein nutrition is not justified.

Albuked 25 should always be administered by intravenous infusion. Albuked 25 may be administered either undiluted or diluted in 0.9% Sodium Chloride or 5% Dextrose in Water. If sodium restriction is required, Albuked 25 should only be administered either undiluted or diluted in a sodium-free carbohydrate solution such as 5% Dextrose in Water.

A number of factors beyond our control could reduce the efficacy of this product or even result in an ill effect following its use. These include improper storage and handling of the product after it leaves our hands, diagnosis, dosage, method of administration, and biological differences in individual patients. Because of these factors, it is important that this product be stored properly and that the directions be followed carefully during use.

Hypovolemic Shock—For treatment of hypovolemic shock, the volume administered and the speed of infusion should be adapted to the response of the individual patient.

Burns—After a burn injury (usually beyond 24 hours) there is a close correlation between the amount of albumin infused and the resultant increase in plasma colloid osmotic pressure. The aim should be to maintain the plasma albumin concentration in the region of 2.5 ± 0.5 g per 100 mL with a plasma oncotic pressure of 20 mm Hg (equivalent to a total plasma protein concentration of 5.2 g per 100 mL). (2) This is best achieved by the intravenous administration of Albuked 25. The duration of therapy is decided by the loss of protein from the burned areas and in the urine. In addition, oral or parenteral feeding with amino acids should be initiated, as the long-term administration of albumin should not be considered as a source of nutrition.

Hypoproteinemia With or Without Edema— Unless the underlying pathology responsible for the hypoproteinemia can be corrected, the intravenous administration of Albuked 25 must be considered purely symptomatic or supportive (see section Situations in Which Albumin Administration is Not Warranted). (2) The usual daily dose of albumin for adults is 50 to 75 g and for children 25 g. Patients with severe hypoproteinemia who continue to lose albumin may require larger quantities. Since hypoproteinemic patients usually have approximately normal blood volumes, the rate of administration of Albuked 25 should not exceed 2 mL per minute, as more rapid injection may precipitate circulatory embarrassment and pulmonary edema.

Other dosage recommendations are given under the specific indications referred to above.

Adverse reactions to albumin are rare. Such reactions may be allergic in nature or due to high plasma protein levels from excessive albumin administration. Allergic manifestations include urticaria, chills, fever, and changes in respiration, pulse and blood pressure.

Albumin (Human) 25%, USP (Albuked™ 25) is made from large pools of human venous plasma by the Cohn cold ethanol fractionation process. Part of the fractionation may be performed by another licensed manufacturer. It is prepared in accordance with the applicable requirements established by the U.S. Food and Drug Administration.

Albuked 25 is a 25% sterile solution of albumin in an aqueous diluent. The preparation is stabilized with 0.02 M sodium caprylate and 0.02 M acetyltryptophan. The aluminum content of the product is not more than 200 µg/L. The approximate sodium content of the product is 145 mEq/L. Albuked 25 is clear, slightly viscous, almost colorless to yellow, amber or green. It contains no preservative. Albuked 25 must be administered intravenously.

Each vial of Albuked 25 is heat-treated at 60°C for 10 hours against the possibility of transmitting the hepatitis viruses.

Additionally, the manufacturing process was investigated for its capacity to decrease the infectivity of an experimental agent of transmissible spongiform encephalopathy (TSE), considered as a model for the variant Creutzfeldt-Jakob disease (vCJD) and Creutzfeldt-Jakob disease (CJD) agents. (11-14) The production steps from Pooled Plasma to Effluent IV-1 in the Albuked 25 manufacturing process have been shown to decrease TSE infectivity of that experimental model agent (a total of ≥7.0 logs). These studies provide reasonable assurance that low levels of vCJD/CJD agent infectivity, if present in the starting material, would be removed.

Each 20 mL vial of Albuked 25 supplies the oncotic equivalent of approximately 100 mL citrated plasma; 50 mL supplies the oncotic equivalent of approximately 250 mL citrated plasma.

When administered intravenously to an adequately hydrated subject, the oncotic (colloid osmotic) effect of 20 mL Albuked 25 is such that it will draw approximately a further 70 mL of fluid from the extravascular tissues into the circulation within 15 minutes, (1) thus increasing the total blood volume and reducing both hemoconcentration and whole blood viscosity. Accordingly, the main clinical indications are for hypoproteinemic states involving reduced oncotic pressure, with or without accompanying edema. (2) Albuked 25 can also be used as a plasma volume expander.

Albumin is a transport protein and it may be useful in severe hemolytic disease in the neonate who is awaiting exchange transfusion. The infused albumin may reduce the level of free bilirubin in the blood. (2,3) This could also be of importance in acute liver failure where albumin might serve the dual role of supporting plasma oncotic pressure, as well as binding excessive plasma bilirubin. (2)