What are the guidelines for performing massive volume paracentesis?

Guidelines for Performing Massive Volume Paracentesis

Large volume paracentesis (LVP) should be performed in a single session with albumin infusion at a dose of 8g albumin per liter of ascites removed when the volume exceeds 5 liters. 1

Indications and Patient Selection

• LVP is the first-line treatment for patients with tense or refractory ascites, providing faster relief than diuretic therapy alone 1
• An initial LVP rapidly relieves tense ascites and should be followed by sodium restriction and diuretic therapy to prevent reaccumulation 1
• Patients with diuretic-sensitive ascites should preferably be treated with sodium restriction and oral diuretics rather than serial paracenteses 1

Procedure Technique

• Paracentesis should be performed under strict sterile conditions 1
• Ultrasound guidance should be considered when available to reduce the risk of adverse events such as bleeding complications 1
• The needle should be inserted using the "Z" track technique (skin penetrated perpendicularly, then advanced obliquely in subcutaneous tissue) 1
• All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 1-4 hours 1
• The drain should not be left in overnight 1

Volume Management and Albumin Administration

• For paracentesis removing >5 liters of fluid, albumin (20% or 25% solution) should be infused at a dose of 8g albumin per liter of ascites removed 1
• For paracentesis removing <5 liters, plasma expansion is generally not necessary unless there is evidence of acute-on-chronic liver failure (ACLF) 1
• Albumin should be administered after the paracentesis is completed 1
• Larger volumes of ascitic fluid (>8 liters) have been safely removed with proper albumin administration, but it's preferable to limit removal to less than 8 liters in a single procedure 1

Prevention of Paracentesis-Induced Circulatory Dysfunction (PICD)

• PICD occurs in up to 70% of cases when paracentesis is performed without plasma expansion 1
• PICD is associated with increased rates of recurrent ascites, development of hepatorenal syndrome, hyponatremia, and reduced survival 1
• Albumin has been shown to be superior to other volume expanders for preventing PICD 1
• Some studies suggest that lower doses of albumin (4g per liter of ascites removed) may be effective in preventing PICD-related renal impairment, but this is not yet reflected in guidelines 2

Post-Procedure Management

• After paracentesis, the patient should lie on the opposite side for two hours if there is leakage of remaining ascitic fluid 1
• A suture (ideally purse string) can be inserted around the drainage site to minimize the risk of ascitic fluid leakage 1
• Diuretics should be reintroduced within 1-2 days after paracentesis to prevent reaccumulation of ascites 3
• Without diuretic therapy, ascites recurs in approximately 93% of patients, but with spironolactone treatment, recurrence drops to only 18% 3

Monitoring for Complications

• Hemodynamic changes after LVP are maximal at 3 hours post-procedure 3
• Pulmonary capillary wedge pressure decreases at 6 hours and continues to fall without proper colloid replacement 3
• Monitor for signs of post-paracentesis circulatory dysfunction, such as hypotension 3
• Routine follow-up paracentesis is not needed in patients with uncomplicated paracentesis and typical clinical response 3

Common Pitfalls to Avoid

• Failure to restart diuretics after paracentesis leads to rapid reaccumulation of ascites 3
• Overlooking subtle signs of infection that would warrant repeat paracentesis 3
• Performing unnecessary routine follow-up paracentesis in patients with typical clinical response increases risk without clinical benefit 3
• Not administering albumin after large volume (>5L) paracentesis, which significantly increases the risk of PICD 1, 4