From the Guidelines
The safest amount of ascitic fluid to remove during paracentesis is generally up to 5 liters at one time for large-volume therapeutic paracentesis. For diagnostic purposes, only 50-100 mL is typically needed [ 1 ]. When performing therapeutic paracentesis for symptom relief, it's recommended to start with 1-2 liters and assess patient tolerance before removing more fluid. Removing larger volumes (>5 liters) in a single session increases the risk of paracentesis-induced circulatory dysfunction (PICD), which can lead to rapid reaccumulation of ascites, hypotension, and renal impairment [ 1 ]. To minimize these risks when removing larger volumes, intravenous albumin administration (6-8 g per liter of ascitic fluid removed) is recommended as volume expansion [ 1 ].
Some key points to consider when performing paracentesis include:
- Using a 22-gauge needle or small catheter inserted into the lower quadrant of the abdomen
- Avoiding visible blood vessels, surgical scars, and areas of infection
- Monitoring patients for complications including hypotension, bleeding, infection, and bowel perforation during and after the procedure
- Administering albumin infusion at the time of large-volume paracentesis (>5 L) to mitigate the risk of PPCD [ 1 ]
- Considering albumin infusion after paracentesis of <5 L in patients with ACLF or high risk of post-paracentesis acute kidney injury [ 1 ]
The recommended dose of albumin replacement is 6-8 g for every liter of ascites removed, based on expert opinion [ 1 ]. It's essential to note that paracenteses of a smaller volume are not associated with significant hemodynamic changes, and albumin infusion may not be required [ 1 ]. However, when removing larger volumes, the administration of 6-8 g of albumin per liter of ascites removed has been shown to be effective in preventing PPCD [ 1 ].
From the Research
Safest Amount of Ascitic Fluid to Remove
- The safest amount of ascitic fluid to remove during paracentesis is not explicitly stated in the provided studies, but it is generally considered that removing over 5 L of ascitic fluid can become a time-consuming and labor-intensive process 2.
- A study published in 2020 suggests that removing 5-6 L, 7-10 L, or more than 10 L of ascitic fluid requires standardized albumin doses of 25 g, 50 g, and 75 g, respectively 3.
- Another study published in 2015 found that administering 4 grams of albumin per liter of ascitic fluid removed can prevent paracentesis-induced circulatory dysfunction (PICD) related renal impairment in cirrhosis, regardless of the volume of fluid removed 4.
- The removal of at least 5L of ascitic fluid is considered large-volume paracentesis, which is used to reduce intra-abdominal pressure and relieve symptoms of abdominal ascites 5.
- Paracentesis-induced circulatory dysfunction (PICD) is a significant complication of large-volume paracentesis, and its prevention is crucial to avoid faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival 6.
Key Considerations
- The amount of ascitic fluid removed during paracentesis should be individualized based on the patient's condition and the presence of any complications 3, 4.
- Standardized albumin dosing based on the volume of ascitic fluid removed can help reduce the risk of PICD and other complications 3.
- Nurses play a crucial role in monitoring patients undergoing paracentesis and administering treatment as directed by the medical team 5.