When to remove an ascitic fluid drain?

From the Guidelines

Ascitic drains should be removed when the drainage output decreases to less than 50-100 mL per 24 hours, which typically occurs within 3-5 days after placement, considering the patient's clinical condition and absence of complications 1.

Key Considerations for Drain Removal

• The decision to remove the drain should also consider resolution of symptoms such as abdominal distension and respiratory distress, improvement in the patient's clinical condition, and absence of complications like infection or leakage around the catheter site.
• Prior to removal, the drain should be clamped for 4-6 hours to ensure that ascites does not reaccumulate rapidly, as suggested by the management of patients with grade 3 ascites 1.

Procedure for Removal

• The procedure for removal involves removing any securing sutures, applying gentle traction to withdraw the catheter, and immediately covering the site with an occlusive dressing to prevent fluid leakage.
• After removal, the site should be monitored for 24-48 hours for signs of leakage, infection, or reaccumulation of ascites.

Rationale for Early Removal

• Early removal helps minimize the risk of infection, while leaving the drain in place too long increases the risk of peritonitis, catheter-related infections, and protein loss through continuous drainage, which can lead to circulatory dysfunction and other complications 1.
• In cases of therapeutic paracentesis for symptom relief, the drain is typically removed immediately after the procedure is completed, as the goal is to provide temporary relief from symptoms rather than long-term management of ascites.

From the Research

Removal of Ascitic Fluid Drain

The decision to remove an ascitic fluid drain depends on various factors, including the patient's condition, the type of drain, and the presence of complications.

• The studies do not provide a specific timeline for the removal of an ascitic fluid drain 2, 3, 4, 5, 6.
• However, it is essential to monitor the patient's condition and adjust the treatment plan accordingly.
• For example, if the patient has refractory ascites, a permanent-tunneled peritoneal catheter can be considered as a viable treatment alternative 4.
• In general, the management of ascites involves a combination of sodium restriction, diuretics, and large-volume paracentesis (LVP) 2, 3, 5, 6.
• The use of diuretics, such as spironolactone and furosemide, can help eliminate ascitic fluid and reduce the need for repeated paracenteses 2, 3.
• LVP can provide immediate relief from ascites and its associated symptoms, but it may require repeated hospitalizations and paracenteses 2, 3.
• The placement of a tunneled peritoneal drainage catheter can reduce the need for paracentesis and diuretic intake, while avoiding hyponatremia, worsening kidney function, and albumin infusions 4.

Complications and Considerations

• Spontaneous bacterial peritonitis is a common complication of ascites, and patients at risk should be considered for prophylaxis with an orally administered quinolone (eg, norfloxacin) 2.
• The development of refractory ascites is particularly ominous, and liver transplantation is the only effective therapy for patients with refractory ascites associated with cirrhosis 2, 6.
• The use of peritoneovenous shunts is limited by the high incidence of complications induced by the procedure, and approximately 40% of patients develop an obstruction of the prosthesis within the first postoperative year 3.