What are the guidelines for draining abdominal ascites with an indwelling paracentesis catheter in hospice patients, including volume limits and blood pressure monitoring?

Guidelines for Draining Abdominal Ascites with Indwelling Paracentesis Catheter in Hospice Patients

For hospice patients with abdominal ascites requiring an indwelling paracentesis catheter, all ascitic fluid should be drained to dryness in a single session over 1-4 hours, with careful monitoring of blood pressure to avoid complications such as hypotension. 1

Volume Considerations

• Complete drainage to dryness in a single session is recommended by guidelines to minimize complications 2, 1
• Limit drainage to less than 8 liters per session to minimize the risk of post-paracentesis circulatory dysfunction 1
• For terminally ill cancer patients, even small-volume paracentesis (1500-2500 mL) can provide symptom relief without shortening the interval between procedures compared to moderate-volume paracentesis (>2500 mL) 3

Blood Pressure Monitoring and Precautions

• Monitor for signs of hypotension during and after the procedure, as fatal hypotension has been reported in the first 24 hours after catheter insertion (4.4% acute catheter-related mortality rate) 4
• Avoid rapid drainage of peritoneal fluid to prevent circulatory collapse 4
• Consider albumin replacement for large volume paracentesis (>5 liters) at a dose of 8g albumin per liter of ascites removed to prevent post-paracentesis circulatory dysfunction 2, 1

Catheter Management

• The puncture site should be at least 8 cm from the midline and 5 cm above the symphysis to minimize risk of injury to vessels or organs 2
• Use ultrasound guidance when available to reduce the risk of adverse events 2, 1
• After paracentesis, have the patient lie on the opposite side for two hours if there is leakage of remaining ascitic fluid 2
• Consider a purse-string suture around the drainage site to minimize the risk of ascitic fluid leakage 2
• Avoid leaving the drain in overnight to reduce infection risk 2, 1

Infection Prevention

• Perform the procedure under strict sterile conditions 2
• Be aware that indwelling catheters carry a risk of catheter-related sepsis (reported rate of 1.6 episodes per 100 catheter-days) 4
• Monitor for signs of infection, as 35.1% of patients with indwelling catheters for malignant ascites developed catheter-related sepsis in one study 4

Benefits in Hospice Setting

• Home-based paracentesis with indwelling catheters provides immediate symptomatic relief and good patient/caregiver satisfaction 5, 6
• This approach eliminates the distress associated with transporting hospice patients for outpatient or inpatient procedures 5
• Indwelling catheters can provide durable symptom relief, avoiding the hazards and disadvantages of multiple repeat procedures 4, 7

Important Caveats

• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 2
• Beta-blockers should be used with caution in patients with refractory ascites, with careful monitoring of blood pressure and renal function 2
• Be vigilant for potential complications including catheter blockage (13.5%), loculated ascites (5.4%), and premature catheter removal 4
• Consider the patient's overall condition and goals of care when determining the appropriate drainage volume and frequency

Home-based palliative paracentesis has been shown to be safe and effective for hospice patients with symptomatic ascites, with studies reporting appreciable symptom relief and no significant complications 5, 6.