From the Guidelines
Blood pressure medications should be held on the day of paracentesis to minimize hypotension risk, especially ACE inhibitors, ARBs, and diuretics which can exacerbate post-procedure hypotension. For patients with severe hypertension, beta-blockers and calcium channel blockers may be continued as they pose less risk. Patients should be instructed to skip their morning dose of antihypertensives on the procedure day but resume their regular schedule afterward. During the procedure, careful monitoring of vital signs is essential, with IV fluids (typically normal saline) prepared for administration if blood pressure drops. This approach is recommended because paracentesis can cause significant fluid shifts as ascitic fluid is removed from the peritoneal cavity, potentially leading to decreased venous return and hypotension, as noted in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
For large-volume paracentesis (>5 liters), albumin administration (6-8 g per liter of fluid removed) should be considered to maintain intravascular volume and further reduce hypotension risk, as supported by the AGA clinical practice update on the use of vasoactive drugs and intravenous albumin in cirrhosis 1. This is crucial to prevent postparacentesis circulatory dysfunction (PPCD), which can lead to renal impairment, dilutional hyponatremia, hepatic encephalopathy, and death. The administration of albumin has been shown to be effective in preventing PPCD, particularly when more than 5 L of ascites are removed, as highlighted in the 2021 guidance 1.
Key considerations for managing blood pressure medication in patients undergoing paracentesis include:
- Holding ACE inhibitors, ARBs, and diuretics on the day of the procedure to minimize hypotension risk
- Continuing beta-blockers and calcium channel blockers in patients with severe hypertension
- Monitoring vital signs closely during the procedure and having IV fluids available to manage potential hypotension
- Administering albumin for large-volume paracentesis to maintain intravascular volume and reduce hypotension risk, as recommended by recent clinical practice updates 1.
From the Research
Management of Blood Pressure Medication for Paracentesis Patients
To minimize the risk of hypotension in patients undergoing paracentesis, careful management of blood pressure medication is crucial. The following points should be considered:
- Patients with hypertension undergoing paracentesis require special attention to their blood pressure management to avoid complications such as hypotension 2.
- Large-volume paracentesis can lead to a decrease in intra-abdominal pressure, which may result in hypotension 3, 4.
- The removal of a large volume of ascitic fluid can cause a significant shift in blood volume, potentially leading to hypotension 4.
- Discontinuing certain blood pressure medications, such as angiotensin receptor blockers or angiotensin-converting enzyme inhibitors, before the procedure may help reduce the risk of intraoperative hypotension 2.
- Close monitoring of the patient's blood pressure and hemodynamic status during and after the procedure is essential to promptly identify and manage any potential complications 5, 6.
- The use of intravenous albumin or other volume expanders may be considered to help maintain blood pressure and prevent hypotension 5, 4.
Key Considerations
- The patient's underlying medical conditions, such as cirrhosis or heart disease, should be taken into account when managing their blood pressure medication 5, 3.
- The potential risks and benefits of continuing or discontinuing blood pressure medication should be carefully weighed on a case-by-case basis 2.
- Effective communication between the healthcare team, including nurses, physicians, and anesthesiologists, is critical to ensure optimal management of the patient's blood pressure medication during the paracentesis procedure 3, 2.