Indications for Leaving a Catheter in Place After Paracentesis for Ascites
There are no standard indications to leave a catheter in place after paracentesis for ascites in most patients with cirrhosis, as guidelines recommend complete drainage in a single session followed by catheter removal. 1, 2
Standard Paracentesis Procedure
Recommended Approach
- Complete all ascitic fluid drainage to dryness in a single session over 1-4 hours 1
- Remove the catheter after the procedure is complete 1
- Have the patient lie on the opposite side for 2 hours if there is leakage of remaining ascitic fluid 1
- Consider placing a purse-string suture around the drainage site to minimize leakage 1
Rationale for Single-Session Drainage
- Total paracentesis is safer and more effective than repeated small-volume paracenteses 2
- Leaving the drain in overnight is not recommended 1
- Guidelines explicitly recommend against repeated low-volume paracentesis, which offers no additional benefits and carries a higher risk of procedure-related complications 1
Potential Exceptions: Indwelling Catheter Considerations
While not standard practice for most patients with cirrhosis, permanent tunneled peritoneal catheters may be considered in specific circumstances:
Potential Indications for Tunneled Peritoneal Catheters
- Refractory ascites requiring very frequent paracentesis (multiple times per week) 3
- Patients with contraindications to TIPS (transjugular intrahepatic portosystemic shunt) 3
- Malignant ascites, particularly when rapid re-accumulation necessitates frequent procedures 4
Benefits and Risks of Indwelling Catheters
Benefits:
- Reduced need for repeated hospital visits for paracentesis 3
- Potential for home-based drainage management 3
- Stable kidney function, serum sodium, and albumin levels despite frequent drainage 3
Risks:
- Catheter-related infections (rate of 1.6 episodes per 100 catheter-days) 4
- Potential for catheter blockage (13.5% of cases) 4
- Risk of bacterial colonization and peritonitis 5
- Rare but serious complications including hypotension 4
Important Considerations for Standard Paracentesis
- Use ultrasound guidance to reduce the risk of adverse events 1, 2
- Ensure the puncture site is at least 8 cm from the midline and 5 cm above the symphysis 1, 2
- Administer albumin (8g per liter of ascites removed) for large-volume paracentesis (>5 liters) 2
- Consider albumin administration even for smaller-volume paracentesis (<5 liters) in high-risk patients (those with acute-on-chronic liver failure) 2
- Reintroduce diuretics within 1-2 days after paracentesis 1, 2
Conclusion
The standard of care for paracentesis in cirrhotic ascites is to complete the drainage in a single session and remove the catheter afterward. Permanent or tunneled catheters should be reserved for specific situations like refractory ascites with very frequent paracentesis requirements or malignant ascites, with careful consideration of the increased infection risk.