HM is a 63-year-old male who presents to the ICU with ascites and a fever. Paracentesis was performed to aspirate the ascites, and the fluid was cultured. Preliminary culture results yielded lactose-positive gram-negative rods. HM was empirically started on Rocephin 2g IV QD for 5 days. The PA covering HM’s case would also like to start albumin 25% at 1.5g/kg on Day 1 and 1g/kg on Day 3.

PMH: Liver Cirrhosis; HTN; HLD

Current medications: Lisinopril 20 mg PO QD; amlodipine 10 mg PO QD; atorvastatin 20 mg PO QD; lactulose 25 mL PO TID; Lasix 80 mg PO QD; Aldactone 200 mg PO QD

Vitals:

Wt: 103.3 kg               Ht: 73 in          Temp: 101.1°F

HR: 110 bpm               BP: 145/82 mmHg                  RR: 16              SpO2: 96%

Pertinent Labs:

Hgb: 10.2 g/dL            WBC: 7500/mm³

Na: 130 mEq/L             K: 3.9 mEq/L                BUN: 20                       SCr: 1.1 mg/dL

Albumin: 3.1 g/dL

Ascites Cytology and Culture Preliminary Results:

PMN: 1270 cells/mm³

Albumin: 2 g/dL

Lactose-positive gram-negative rods

Based on this dosing regimen, how much albumin, in milliliters, would HM receive on Day 1 and Day 3? Construct your response to the nearest whole number mL for each day using actual body weight. 

Rationale:

Brands/Generics covered: Rocephin (ceftriaxone); Lasix (furosemide); Aldactone (spironolactone)

Ascites, described as fluid accumulation in peritoneal cavity, is a common complication in patients with liver cirrhosis. Poor hepatic blood flow causes venous congestion. In combination with venous congestion caused by poor hepatic blood flow, hypoalbuminemia causes fluid leakage from vessels into the peritoneal space due to a marked reduction in oncotic pressure. Ascites can become infected, which is known as Spontaneous Bacterial Peritonitis (SBP). Enterobacterales, which are characterized most often as lactose-positive gram-negative rods, are the typical primary causative organisms. Third generation cephalosporins are the mainstays of treatment, with ceftriaxone being a common chosen option.

Furthermore, albumin 25% is used to reduce the risk of immediate ascitic fluid re-accumulation, as well protect against renal dysfunction caused by SBP. The concentration of albumin products are presented as weight-by-volume. Therefore, albumin 25% is equivalent to 25g/100mL. Based on the patient’s weight of 103.3 kg, the dose on Day 1 and 2 is 155 g and 103 g, respectively. Now we must determine how many milliliters of albumin 25% is required to deliver these doses. Since every 100 mL contains 25 g of albumin, we can use a ratio and cross multiplication to determine how many milliliters is needed.

25g/100mL = 155g/x

x = 620 mL

25g/100 mL = 103g/x

x = 412 mL

It is important to be able to perform calculations from beginning to end. One of the question types on the NAPLEX is a constructed response or "fill in the blank" so to speak. This will require you to calculate and enter the answer on the exam. 

NAPLEX Competencies Covered:

Area 3 (Develop or Manage Treatment Plans), 3.3 Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions, 3.4 Drug dosing or dosing adjustments; duration of therapy. Area 4 (Perform Calculations), 4.2 Quantities of drugs to be dispensed or administered, 4.5 Drug concentrations, ratio strengths, osmolarity, osmolality, or extent of ionization.