Hospital Pharmacy - April 2020 - 90

823727
research-article2019

HPXXXX10.1177/0018578718823727Hospital PharmacyTorbic et al

Critical Care Series

Evaluation of Albumin 25% Use in
Critically Ill Patients at a Tertiary
Care Medical Center

Hospital Pharmacy
2020, Vol. 55(2) 90-95
© The Author(s) 2019
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https://doi.org/10.1177/0018578718823727
DOI: 10.1177/0018578718823727
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Heather Torbic1, Seth R. Bauer1, Michael Militello1,
Sarah Welch1, Chiedozie Udeh1, and Steven Richardson2

Abstract
Background: Albumin 25% has been studied and has demonstrated benefit in a limited number of patient populations. The
use of albumin 25% is associated with higher costs compared with crystalloid therapy. The aim of this study was to describe
the prescribing practices of albumin 25% at a tertiary-care medical center and identify opportunities for restriction criteria
related to its use to help generate cost savings. Methods: This evaluation was a retrospective, noninterventional, descriptive
study of albumin 25% use between June 2015 and February 2016. Inclusion criteria consisted of patients ≥18 years old and
who received at least one dose of albumin 25% while admitted to a Cleveland Clinic main campus intensive care unit (ICU).
Inclusion was restricted to 150 randomly selected patients. Results: A total of 539 albumin 25% orders were placed for the
150 included patients. The cardiovascular ICU more frequently prescribed albumin 25% compared with the medical, surgical,
neurosciences, and coronary ICUs (51% vs 23% vs 11% vs 9% vs 6%, respectively). Although the cardiovascular surgery ICU
most frequently prescribed albumin 25% compared with other ICUs, the medical ICU prescribed a larger total quantity of
albumin 25% compared with the cardiovascular, surgical, neurosciences, and coronary ICUs (8705 g vs 7275 g vs 3205 g vs
2162 g vs 625 g, respectively). The majority of patients (61%) did not have an indication listed for albumin 25% use and only
9% of patients were prescribed for indications supported by primary literature. Of the patients prescribed albumin for other
indications not supported by primary literature (30%), the most common reasons for albumin 25% were hypotension, acute
kidney injury, and volume resuscitation. The median cost per patient of albumin 25% was $417 with a total cost of $122
164 for the cohort. Only 19% of the total cost aligned with dosing regimens evaluated in primary literature. Conclusion:
Prescribing patterns of albumin 25% at a tertiary academic medical center do not align with indications supported by primary
literature. These findings identified a major opportunity for prescriber education and implementation of restriction criteria
to target cost savings.
Keywords
albumin, critical care, cost avoidance, formulary restrictions, prescribing patterns

Background
Albumin is a colloid fluid frequently prescribed in the intensive care unit (ICU) for a variety of indications, primarily
volume expansion and fluid resuscitation. Albumin, compared with crystalloid therapy, has not demonstrated a benefit in regard to hospital length of stay, duration of mechanical
ventilation, or mortality when used for volume resuscitation
or albumin supplementation.1-3 The Surviving Sepsis
Campaign Guidelines provide a weak recommendation, due
to low-quality evidence, for albumin therapy for initial resuscitation and subsequent intravascular volume repletion in
patients with sepsis or septic shock after they have received
large quantities of crystalloid therapy, suggesting that albumin 5% would be preferred in this setting.4 Albumin is

available in many concentrations and the more concentrated
25% has been studied for a few specific indications in which
it may provide benefit compared with 5% albumin. The
indications include vasospasm post-subarachnoid hemorrhage (SAH), large-volume paracentesis, hepatorenal syndrome (HRS), spontaneous bacterial peritonitis (SBP), and
intradialytic hypotension.5 The American Heart Association
1

Cleveland Clinic, OH, USA
Kaweah Delta Health Care District, Visalia, CA, USA

2

Corresponding Author:
Heather Torbic, Medical ICU Clinical Pharmacist, Department of
Pharmacy, Cleveland Clinic, 9500 Euclid Avenue, Hb-105, Cleveland, OH
44195, USA.
Email: torbich@ccf.org
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