From the Guidelines
Paracentesis should be performed in patients with new-onset Grade 2 or 3 ascites, hospitalized for worsening ascites, or with any complication of cirrhosis, including fever, abdominal pain, gastrointestinal bleeding, hepatic encephalopathy, hypotension, or renal insufficiency, as recommended by the most recent guidelines 1. When deciding to perform a paracentesis, several factors should be considered, including the presence of symptoms, signs of infection, and the patient's overall clinical condition.
- The procedure is indicated for diagnostic purposes when ascites is first detected to determine its etiology through fluid analysis.
- Therapeutic paracentesis is warranted when patients experience symptoms like abdominal pain, early satiety, shortness of breath, or restricted mobility due to large-volume ascites.
- Signs of infection such as fever, abdominal pain, altered mental status, or worsening liver or kidney function in a patient with ascites should prompt an urgent diagnostic paracentesis to rule out SBP, as suggested by previous guidelines 1. The procedure involves inserting a needle into the peritoneal cavity, typically in the left or right lower quadrant, after local anesthesia with 1-2% lidocaine.
- For large-volume paracentesis (>5 liters), intravenous albumin (6-8 g per liter of fluid removed) should be administered to prevent post-paracentesis circulatory dysfunction, as recommended by recent guidelines 1. Contraindications include coagulopathy, thrombocytopenia below 20,000/μL, pregnancy, distended bowel, abdominal wall cellulitis, or previous abdominal surgery at the puncture site.
- Ultrasound guidance increases safety and success rates, especially in patients with small amounts of ascites or multiple abdominal surgeries. It is essential to weigh the benefits and risks of paracentesis, considering the patient's individual condition and the potential complications, such as hemorrhage, which occurs in 0.2-2.2% of punctures, as reported in the guidelines 1.
From the Research
Indications for Paracentesis
- Paracentesis is used to reduce intra-abdominal pressure and to relieve the symptoms of abdominal ascites, such as severe abdominal distention, pain, and dyspnoea (difficulty breathing) 2
- The removal of at least 5L of ascitic fluid is considered large-volume paracentesis 2
- Diagnostic paracentesis should be performed in all patients with new-onset ascites or with known ascites and any change in their condition, such as the appearance of fever, abdominal pain, renal insufficiency, or encephalopathy 3
Timing of Paracentesis
- Paracentesis is considered in patients with refractory ascites, which is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment (diuretic-resistant) or when there is an inability to reach maximal dose of diuretics because of adverse effects (diuretic-intractable) 4
- Therapeutic paracentesis associated with intravenous albumin infusion is the treatment of choice for cirrhotic patients with tense ascites 5
- Paracentesis may be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver functions, and TIPS placement or liver transplantation should be discussed 4, 6
Benefits and Risks of Paracentesis
- Large-volume paracentesis associated with intravenous albumin infusion is more effective than diuretic therapy in eliminating the ascitic fluid, and is associated with a lower incidence of complications (hepatic encephalopathy, renal impairment, and hyponatremia) 5
- The mobilization of the ascitic fluid by paracentesis without plasma volume expansion is constantly associated with a deterioration of effective circulating blood volume and may induce renal impairment and severe hyponatremia 5
- Knowledge of the benefits and risks of paracentesis is essential to provide safe, evidence-based care for patients undergoing paracentesis 2