What is the maximum recommended volume for paracentesis at one time?

Maximum Recommended Volume for Paracentesis

The maximum recommended volume for paracentesis should be limited to 8 liters per session to minimize the risk of paracentesis-induced circulatory dysfunction (PICD), with appropriate albumin replacement of 6-8 grams per liter of ascites removed. 1, 2

Understanding Volume Limitations in Paracentesis

While historically there has been debate about volume limitations during paracentesis, current evidence and guidelines provide clear recommendations:

• The American Association for the Study of Liver Diseases (AASLD) 2021 practice guidance indicates that the risk of post-paracentesis circulatory dysfunction (PPCD) increases significantly when more than 8 liters of fluid are evacuated in a single session 1
• Limiting paracentesis to less than 8 liters per session with appropriate albumin replacement may better preserve renal function and improve survival over time 1, 2
• Paracentesis volumes exceeding 8 liters increase hemodynamic stress on an already compromised circulatory system in patients with advanced liver disease 2

Albumin Replacement Guidelines

Proper albumin replacement is critical when performing large-volume paracentesis:

• For paracentesis >5 liters (defined as large-volume paracentesis or LVP):

  • Administer 6-8 grams of albumin per liter of ascites removed 1, 2
  • Albumin should be administered immediately after paracentesis completion 2
  • Some centers divide the dose, giving half immediately and half 6-8 hours later 2

• For paracentesis <5 liters:

  • In patients with acute-on-chronic liver failure (ACLF), albumin should still be administered at 6-8 g/L regardless of volume removed 1, 3
  • In stable cirrhotic patients without ACLF, albumin may not be necessary for volumes <5L, though this remains controversial 2

Clinical Evidence Supporting Volume Limitation

A recent study demonstrated that by limiting paracentesis volume to <8L per session and providing adequate albumin replacement (9.0 ± 2.5g per liter), renal function and survival were better preserved over a mean period of 2 years, despite 40% of patients developing PPCD 1.

Another study examining subtotal paracentesis (≤8L) with albumin infusion (9 ± 3g/L) showed that this approach was safe and effective in managing patients with refractory ascites 4.

Risks of Excessive Volume Removal

Removing excessive volumes of ascites in a single session can lead to:

• PPCD/PICD, which occurs in up to 70% of untreated patients 2
• Renal impairment and acute kidney injury 1, 3
• Hyponatremia 2, 3
• Hepatic encephalopathy 3
• Increased mortality 1, 3

Practical Considerations

• Use ultrasound guidance when available to reduce complications 2
• Perform paracentesis under strict sterile conditions 2
• Routine correction of coagulation parameters is not necessary before paracentesis when performed by experienced personnel 5
• For patients requiring frequent large-volume paracentesis for refractory ascites, consider transjugular intrahepatic portosystemic shunt (TIPS) as a more definitive treatment 1

Common Pitfalls to Avoid

• Removing >8L in a single session without considering the increased risk of PPCD
• Inadequate albumin replacement (less than 6-8g/L of ascites removed)
• Failing to monitor for signs of PPCD after large-volume paracentesis
• Not considering TIPS for patients requiring frequent large-volume paracentesis

By adhering to the 8-liter volume limitation with appropriate albumin replacement, clinicians can safely and effectively manage patients requiring paracentesis while minimizing complications.