When to Reach for Albumin in Sepsis and Septic Shock: A Step-by-Step Reference Guide for Emergency Physicians

Abstract Purpose of Review To provide emergency physicians with a clear, evidence-based, and practical approach to deciding when and how to use albumin in the management of sepsis and septic shock in the emergency department (ED). This review outlines a five-step clinical framework that integrates current guidelines, trial data, and ED-specific considerations to guide albumin use in selected patient populations. Recent Findings Crystalloids remain the first-line fluid resuscitation for sepsis, as recommended by the Surviving Sepsis Campaign (SSC). However, albumin may offer clinical benefit in cases of fluid-refractory hypotension, volume overload, hypoalbuminemia (<2.5 g/dL), septic shock with capillary leak, and in special populations such as patients with cirrhosis, nephrotic syndrome, or burns. Summary Albumin is not a first-line resuscitation fluid, but has a role in specific ED scenarios where crystalloids alone may be insufficient or potentially harmful. A structured, stepwise framework can help emergency physicians identify when albumin may improve hemodynamics, minimize fluid overload, and support vascular integrity. Judicious use—guided by patient characteristics, response to crystalloids, and coordination with critical care teams—can enhance individualized resuscitation strategies in sepsis and septic shock. A summary of recommendations which can be utilized as a quick bedside reference is found in Table 1.